Eastern State Hospital

Williamsburg, Virginia

PATIENT SATISFACTION SURVEY

Please complete this survey to help us serve you better

PLEASE CHECK THE APPROPRIATE BOX

Date:

-- mm/dd/yy (* required field)

Building:

I feel/ felt free to express my opinions or concerns.

This hospital stay is helping/ has helped me to learn better coping skills.

I am/ was an active participant in my treatment planning.

I am helping/ helped to develop my discharge/ after care plan

I am being/ was treated with respect and dignity while in the hospital.

I feel/ felt better as a result of coming to the hospital.

The hospital has helped me feel hopeful about my personal recovery.

I am/ was given the information I needed about my illness.

I am/ was given the information I need about my medications.

I am/ was given the information I need about why I take medications.

I am/ was given the information I need about my diagnosis.

I am/ was given the information I need about the symptoms of my illness.

I am/ was given information I need about the reasons for my hospitalization.

I am/was given the information I need about my discharge plan

I am/ was given the information I need about groups and activities that are available to me.

I feel / felt safe in the hospital.

The areas I observed during my stay were clean and properly maintained.

What activities have been/ were the most helpful?

The thing(s) I like/liked the most about the hospital:

The thing(s) I would like to change about the hospital:

The most helpful person or people were:

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
E-mail

Please select from the following that best describes you:

Eastern State Hospital

Michelle L. SirmansCopyright © 2003 [Eastern State Hospital]. All rights reserved. Revised: 01/09/08

Michelle L. Sirmans
Copyright © 2003 [Eastern State Hospital]. All rights reserved.
Revised: 01/09/08