(07) 3359 7011 (07) 3359 7022 Holy Spirit Northside 627 Rode Road, Chermside Qld 4032

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Date of Surgery:
Today's date:

Name of Anaesthetist:

Please tell us you
Gender

Age:
18-24 25-34 35-44 45-54 55-64 65-74 75-older 

For the questions below, please answer yes or no and where indicated choose a rating from 1-5, where:
1 is poor
and
5 is excellent

1. Did you have pain before surgery?
 yes no
2. Was your anaesthetist involved in managing your pain before surgery?
 yes no
If yes, how well do you think we managed your pain?
1 2 3 4 5 
Are there any comments you would like to make?

2. Did you feel like you had time to ask your anaesthetist questions before your surgery?
 yes no
How well were those questions answered?
1 2 3 4 5 
Are there any comments you would like to make?

3. Did you understand the information about your anaesthetic that was given to you before your surgery?
 yes no
Are there any comments you would like to make?

4. How useful did you find the information?
1 2 3 4 5 
Are there any comments you would like to make?

5. Did you feel like your anaesthetist listened to you?
 yes no
Are there any comments you would like to make?

6. Did you feel rushed?
 yes no
Are there any comments you would like to make?

7. Did you feel scared or anxious before your surgery?
 yes no
If yes, how well did your anesthetist manage your fear and anxiety?
1 2 3 4 5 
Comments:

8. Did your anesthetist explain to you how you might feel after the surgery?
 yes no
Comments:

9. Did you feel nauseated and/or vomit immediately after the surgery?
 yes no
If yes, how well was it treated?
1 2 3 4 5 
Comments:

10. Were you in pain after the operation?
 yes no
If yes, how effective was your pain treatment?
1 2 3 4 5 
Comments:

11. Were you cold or shivering after the surgery?
 yes no
If yes, how well was it managed?
1 2 3 4 5 
Comments:

12. If you had a positive experience, please tell us about it.

13. If you had a negative experience, please tell us about it.

14. Do you have any suggestions about how your care could have been improved?