Dear Patient,
In an effort to evaluate and improve our skills and services, we are interested in your opinion. We would appreciate your time to complete the following evaluation.

In what city/town did you receive care?
		Excellent	Good	Fair	Poor	No Opinion
1. Overall satisfaction with the care provided by the:
a. Nurse(s)
b. Home Health Aides (if you received services)
c. Physical Therapist (if you received services)
d. Medical Social Worker (if you received services)
e. Occupational Therapist (if you received services)
f. Speech Language Pathologist (if you received services)
2. The staff arrived as scheduled.
3. Staff was courteous and respectful.
4. Staff was knowledgeable and competent.
5. You were involved in decision making regarding our plan of care.
6. You were involved in planning for discharge from home health services.
7. Staff explained procedures related to care.
8. Office staff was courteous and directed phone calls correctly and promptly.
9. Would you use our agency again?
10. Would you recommend our services to others?
11. Additional Comments/Suggestions for Improvement:
Patient’s Name (optional)