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* 1. My Nurse provided me with excellent care.

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* 2. My Physical Therapist, Occupational Therapist and/or Speech Therapist provided me with excellent care.

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* 3. How often did Blossom Ridge providers seem informed and up-to-date about the care you received?

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* 4. How often did Blossom Ridge providers treat you with courtesy, respect and listen carefully to you?

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* 5. How often did Blossom Ridge keep you informed about when they would arrive at your home?

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* 6. What number would you use to rate your care from Blossom Ridge? Blossom Ridge’s goal is 9 or higher. If we didn’t accomplish this what could we have done better?

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* 7. Would you recommend Blossom Ridge to your family or friends if they need home health care? Blossom Ridge’s goal is “definitely yes”. If we didn’t accomplish this what could we have done better?

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* 8. Additional Comments:

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* 9. Optional. Please enter the name or names of your Nurses, Therapist, Social Worker, and Home Health Aide:

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* 10. Optional. Contact Information

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