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2025-2026 Pain Management Clinic

Client Experience Questionnaire

Tell us about your experience! Your feedback helps us to improve the way we provide care. This questionnaire was built upon our Patient Values (Dignity, Respect and Trust, Information Sharing, Participation, Accessibility and Responsiveness and Quality).

If the question does not apply, please leave blank.
Dignity, Respect and Trust:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. I was treated with respect.
b. My privacy was respected as best it could be.
c. My cultural needs were considered. (e.g. individuals’ own beliefs, customs, social standards, traditions or religious beliefs)
d. Before providing care, staff members introduced themselves to me, where appropriate.
e. In general, staff were compassionate.
Information Sharing:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. Staff talked to me about what medications I am taking at home. (e.g. prescription, supplements, herbal, etc.)
b. Staff talked to me about my health care options. (e.g. procedures/tests)
c. My healthcare provider used words I could understand.
d. I had the necessary information needed to make good decisions about my health.
e. The staff kept my information confidential and secure.
Participation:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. Staff involved me or my family/support in making decisions about my care.
b. I was encouraged to take part in my care as much as I was able.
c. My choices were respected.
d. I was comfortable expressing concerns about my care.
Accessibility and Responsiveness:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. My care was well coordinated.
b. I was cared for in a timely manner.
c. I had access to the care I needed.
d. My concerns were taken seriously.
e. I am aware of the Prairie Mountain Health (PMH) services and programs available to get the support I need for my health care journey.
Quality:
(If question does not apply, leave blank)
Always
Usually
Sometimes
Never
a. I saw the health care provider(s) clean their hands before providing my care.
b. My identity was confirmed before receiving care. (e.g. asked my name, checked my wrist band, asked my date of birth)
Quality:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
c. My healthcare provider discussed risks or hazards that could cause falls/slips/trips (e.g. proper footwear, wet floors, icy side walks, uneven surfaces, electrical cords, etc.).
d. I felt staff were up to date on the skills needed to provide my care.
e. Overall, I was satisfied with the quality of care I received.
Pain Management Clinic Program Specific Questions:
(If question does not apply, leave blank)
Strongly Agree
Agree
Disagree
Strongly Disagree
a. I was satisfied with the follow up to my pain management plan.
b. The wait time to access the pain clinic did not negatively affect my pain management care.
c. My emotional/psychological needs were also considered in addition to my medical care.
d. The following health care providers were involved in my care:
Yes
No
N/A
1. Nurse
2. Physiotherapist (PT)
3. Occupational Therapist (OT)
4. Psychologist
Pain Management Clinic Program Specific Questions:
Yes
No
e. I was made aware of group education/counselling (i.e. Introduction to Pain, Exercise, Better Sleep, etc.)
Demographics: (of the patient)
Collected for statistical purposes only to target improvements.
Gender:
Ethnicity
Age:
Comments:
Forward additional concerns or compliments regarding your care to Patient Relations.
Patient Relations: email patientrelations@pmh-mb.ca or
call 1-800-735-6596

Pain Clinic Patient Partner Volunteers Needed!! Someone just like you helped to design this survey!
We want to partner with existing Pain Clinic patients or family members who might be interested in helping us review, design or
provide feedback to our services.

If you would like more information or if you think you might be interested in becoming a Patient Partner, please click on the link below or contact Patient Relations by calling 1-800-735-6596.

https://prairiemountainhealth.ca/forms/patient-partner/
Questions or concerns related to this survey can be sent to ceq@pmh-mb.ca

Thank you for your participation!