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Patient Name:*
Date of Service:*
In an effort to provide the highest quality of care and service to our patients, Elder's Choice, Inc. would like to know your opinion of the care you or your family member received from us. Your input is very valuable. It helps us determine what we are doing right and where we need to make changes to improve our program. Please share your thoughts about our services and our staff.
Services Received:
Skilled Nursing Home Health Aide Social Worker
Occupational Therapy Physical Therapy Speech Therapist
1. Were you informed of the names of Agency personnel providing your care?
YesNo Explain  
2. Were you kept informed of your scheduled visits and any changes in schedule?
YesNo Explain  
3. Were visits made as scheduled?
YesNo Explain  
4. Were there frequent changes in Agency Personnel?
YesNo Explain  
5. At each visits, did you feel as though you received enough time and attention?
YesNo Explain  
6. Did you receive instructions that you could clearly understand and find useful in assisting you to manage your illness/disease?
YesNo Explain  
7. Upon discharge, were you given clear, understandable instructions regarding follow-up care?
YesNo Explain  
8. Do you know how to report complaints/abuse about home care?
YesNo Explain  
9. Was the Staff polite, courteous, well groomed, and appropriately dressed?
YesNo Explain  
10. Would you use our services again if needed?
YesNo Explain  
Would you like someone to contact you about this survey?
If Yes, please leave your contact information so we can get back to you:
Relation to patient:
Best time to call: AM      PM   

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