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* 1. Prior to the procedure:

  YES NO
In your opinion, was the test done quickly enough after you were referred to the clinic?
Did you feel you had access to enough information (web site, clinic staff) to make you feel informed about the test?
Did you feel that everything was explained/presented in a clear, comprehensible manner?
Did you feel that you had received enough information to properly prepare for the test?

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* 2. The day of the Procedure

  YES NO
Did the nurse or doctor discuss what the test involved?
Did the nurse or doctor mention that, although it happens very rarely, there might be risks of doing the test (complications such as bleeding or perforation)?
Before going in for the procedure, did you feel that you had an opportunity to ask the nurses any further questions you may have had?
In the procedure room, did you feel that you had an opportunity to ask the doctor doing the test any further questions you may have had?
Do you feel that you had adequate time in the procedure room and that you and the doctor doing the test were not rushed?
Was the doctor doing the test courteous and considerate?
Were the nurses assisting with the test courteous and considerate?
Was the test more uncomfortable than you thought it would be?

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* 3. At the clinic

  YES NO
Was your journey through the clinic well coordinated?
Were you treated courteously and with respect?
Did you feel adequately informed about what was happening to you and when?
Were you comfortable when waiting for the test?
Was there an excessive delay in waiting for your test?

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* 4. Privacy and Dignity
We appreciate that many people will feel that these tests do invade their privacy and are not always very dignified. But within these limits:

  YES NO
Did you feel that your privacy was respected as best as it could be?
Did you feel that attempts were made to preserve your dignity?

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* 5. Aftercare

  YES NO
Were you given information on what reactions to expect after your procedure?
Did a doctor/nurse explain your test results?
Did you receive a written copy of your test results?
Are you satisfied with the way your results were communicated to you?
Were you given information regarding the follow-up of your care? (i.e. if follow-up was required, who would see you in follow up and when?)

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* 6. What was your overall assessment of the procedure?

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* 7. How did your experience of the test compare with the expectations you had prior to the test?

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* 8. Would you be willing to undergo the same test in the future if your doctor recommended it?

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* 9. Please compare your experience here to your previous colonoscopy experiences:

  YES NO N/A
More positive than the same procedure in a hospital setting
More positive than the same procedure in a different out-of-hospital clinic

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* 10. Comments?

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