* 1. Facility seen at time of service

* 2. Age

* 3. What is your gender?

* 4. What is your ethnicity? (Please select all that apply.)

* 5. Was the pre-operative anesthesia care up to your standards of care?

* 6. How was the communication with your anesthesiologist prior to surgery?

* 7. Did you find your anesthesiologist to act in a professional manner?

* 8. Did your anesthesiologist explain the risks and benefits to your satisfaction?

* 9. Was the anesthesiologist’s explanation of what to expect before surgery to your satisfaction?

* 10. Was the anesthesiologist’s explanation of what to expect after surgery to your satisfaction?

* 11. Was the care you received in the recovery room to your satisfaction?

* 12. If you had any post-op symptoms or discomfort in the recovery room, were you treated to your satisfaction?

* 13. A sore throat or hoarseness is common after general anesthesia. If this occurred to you after your surgery, did the discomfort go away after 24 hours?

* 14. Overall, how satisfied were you with your anesthesia care?

* 15. Would you recommend the physician to others?

* 16. If there is any way we can improve our services to you, please tell us about it

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