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Patient Exit Survey form

Patient exit form – how was your stay?

Which ward are you staying on?(Required)

Communication

How much information about your condition or treatment was given to you?(Required)
Beforehand, how well did hospital staff explain how you might feel after you had the operation(s) or procedure(s)?(Required)
Beforehand, how well did hospital staff explain how you might feel after you had the operations or procedures?(Required)
After the operations or procedures, how well did hospital staff explain how the operation or procedure had gone?(Required)

Ward environment

Were you ever prevented from sleeping at night by any of the following? Please check all the boxes that apply to you.(Required)
How would you rate the hospital food?(Required)

Hospital staff

How clean was the hospital room or ward that you were in?(Required)
Were you able to get a member of staff to help you when you needed assistance?(Required)
Do you think the hospital staff did everything they could to help control your pain?(Required)
Have you come into contact with any volunteers during your stay? (They are often in light blue polo shirts and provide help and support to patients during their stay)(Required)
If yes, were they helpful and friendly?(Required)

Leaving hospital

To what extent did staff involve you in decisions about you leaving hospital?(Required)
To what extent did hospital staff take your family or home situation into account when planning for you to leave hospital?(Required)
Did hospital staff discuss with you whether you would need any additional equipment in your home, or any changes to your home, after leaving the hospital?(Required)

Raising concerns about your care

If you had cause to complain, did you see, or were you given, any information explaining how to complain to the hospital about the care you received?(Required)
Did you raise any concerns about your care or treatment during your stay?(Required)
If yes, did you feel your concerns were taken seriously by hospital staff?(Required)

Overall care

Overall, how would you rate your care out of 10?(Required)

About you

Do you have a recognised disability?(Required)
Consent
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