♦ You should fill out this questionnaire only if you were the patient. You may need to get help from a family member or friend to answer the questions. That’s okay.

♦ Answer all the questions by checking the box to the left of your answer.

♦ Your response to this survey is voluntary but will provide us with important information.

♦ You are sometimes told to skip over some questions in this survey. When this happens, you will see an arrow with a note that tells you what question to answer next, like this:

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Before your procedure

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* 1. Was this your first visit as a patient to the North of Superior Healthcare Group?

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* 2. Before your procedure, did a health professional explain what would happen to you, in a way you could understand?

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* 3. Before your procedure, did a health professional explain any risks and/or benefits in a way you could understand?

Day surgery environment

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* 4. In your opinion, how clean was the day surgery area?

Seeing a surgeon

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* 5. Before your procedure, either on the day of your surgery or in a pre-operation appointment, did you have enough time to talk about your health or medical problem with the surgeon?

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* 6. Before your procedure, did the surgeon listen carefully to what you had to say?

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* 7. Before your procedure, if you had questions to ask the surgeon, did you get answers that you could understand?

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* 8. Did you have confidence and trust in the surgeon examining and treating you?

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* 9. If you had any worries or fears about your condition or treatment, did a surgeon talk with you about them?

Overall about your procedure

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* 10. Did the health professionals treating and examining you introduce themselves?

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* 11. Were you given enough privacy when discussing your condition or procedure?

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* 12. How often, during your most recent day surgery experience, were you involved as much as you wanted to be in decisions about your care and treatment?

Leaving the hospital

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* 13. Before you left the hospital, were you told what would happen next (for example, did you need another appointment, did you need to see your family doctor)?

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* 14. Did you receive enough information from health professionals about what to do if you were worried about your condition or treatment after you left the hospital?

Overall impression

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* 15. Overall, did you feel you were treated with respect and dignity while you were at the hospital?

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* 16. Overall how would you rate the care you received during this visit? 1 being you had a very poor experience and 10 being you had a very good experience.

1 5 10
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i We adjusted the number you entered based on the slider’s scale.

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* 17. Would you recommend this hospital to your friends and family?

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* 18. During the visit, were you respected and your preferences considered regarding your treatment and care plan?

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* 19. During this visit, did you have enough say about your treatment?

About you

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* 20. In general, how would you rate your overall physical health?

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* 21. In general, how would you rate your overall mental or emotional health?

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* 22. What is the highest grade or level of school that you have completed?

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* 23. What is your gender?

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* 24. What is your year of birth?
(Please write in; for example, “1934.”)

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* 25. The following question will help us to better understand the communities that we serve. Do you consider yourself to be . . . (Check all that apply)

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* 26. What is your mother tongue?

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* 27. Is there anything else you would like to share about your visit to the North of Superior Healthcare Group?

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