Please fill out the questionnaire below. The feedback gained from this survey ensures that Northwest Specialty continues our goal of providing the best patient education possible.  We greatly appreciate your participation. 

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* 1. Patient's name:

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* 2. Patient's date of birth:

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* 3. Patient's phone number:

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* 4. Patient's email address:

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* 5. Who is your surgeon?

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* 6. What surgery are you scheduled to have?

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* 7. What is the most important thing you need to do before a dressing change to prevent an infection?

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* 8. After watching the video, I understand that applying _______to my surgical site is an important part of my pain management plan.

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* 9. Symptoms of a surgical site infection include:

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* 10. I understand how to setup my home for safety and fall prevention?

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* 11. Which medication prevents blood clots?

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* 12. Activity and exercises will help aid in my recovery.

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* 13. Please rate the quality of the education you have received.

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* 14. What is your preferred learning style?

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* 15. Was the education viewed by support person(s)? Anyone that will be helping the patient before or after surgery.

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* 16. Do you have any suggestions or comments you would like to share?

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