Patient Survey
*
1.
I am a
(Required.)
Patient
Family member
Caregiver
*
2.
I, or my family member have been in Lake Taupo Hospice care
(Required.)
1 - 3 months
3 - 6 months
+ 6 months
*
3.
I attend or have attended Tuesday Activity Days and/or Friday Club days
(Required.)
Tuesday Activity Day
Friday Club Day
None of the above
*
4.
What I get the most out of Tuesday/Friday groups are
(Required.)
*
5.
I am satisfied with the frequency of contact from Lake Taupo Hospice
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very Satisfied
4 stars
N/A
*
6.
I am satisfied with the information and advice given to me/my family member
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
7.
I am satisfied with the support overall given to me/my family member
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
8.
I am satisfied with the respect shown for my/my family member needs
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
9.
I am satisfied with the management of my/my family member management of symptoms and treatment
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
10.
I am satisfied with the appropriateness of the equipment given to me
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
11.
I am satisfied with the access to nurse advice and support
(Required.)
Not satisfied at all
1 star
Somewhat satisfied
2 stars
Satisfied
3 stars
Very satisfied
4 stars
N/A
*
12.
Please rate your overall experience
(Required.)
My overall experience has not been satisfactory
My overall experience has been satisfactory
My overall experience has been excellent
My overall experience has not been satisfactory
My overall experience has been satisfactory
My overall experience has been excellent
*
13.
I was given assistance to write an Advanced Care Plan
(Required.)
Yes
No
*
14.
My Advanced Care Plan was used in my care
(Required.)
Yes
No
N/A
*
15.
I would recommend Lake Taupo Hospice care and support
(Required.)
Yes
No
*
16.
My suggestions for Lake Taupo Hospice to improve its services are
(Required.)
*
17.
What I appreciated the most about the care and support I/my family member receive/d is
(Required.)