Palliative Care Referring Physician Satisfaction Survey

Question Title

* 1. What region do you primarily practice in?

Anamosa

Cedar Rapids

Des Moines

Dubuque

Fort Dodge

Madison

Muscatine

Peoria

Quad Cities

Quincy

Sioux City

Sac City

Waterloo

Question Title

* 2. Did Palliative Care involvement improve the quality of life for your patient?

Don't Agree at All

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

Don't Agree at All

Somewhat Disagree

Neutral

Somewhat Agree

Strongly Agree

Question Title

* 3. To what degree was Palliative Care helpful for your patient?

Not Helpful at All

Not Very Helpful

Neutral

Somewhat Helpful

Very Helpful

Not Helpful at All

Not Very Helpful

Neutral

Somewhat Helpful

Very Helpful

Question Title

* 4. What comments or suggestions do you have to improve your patient’s experience with Palliative Care?

Question Title

* 5. Contact information for follow up (optional):

Name

Email Address

Phone Number