Satisfaction Survey

1. When you first started getting home health care from this agency, did someone from the agency tell you what care and services you would receive? *
 Yes No

2. Did someone from the agency speak with you regarding the prescription medicines you were taking? *
 Yes No

3. Did someone from the agency ask to see all the prescription medicines you were taking? *
 Yes No

4. Did home health providers from this agency talk with you about when to take all the medicines? *
 Yes No

5. Did you and a home health provider from this agency talk about pain? *
 Yes No

6. How often did home health providers from this agency keep you informed about when they would arrive at your home? *
 Always Never

7. How often did home health providers from this agency carefully listened to you? *
 Always Never

8. How often did home health providers from this agency explain things in a way that was easy to understand? *
 Always Never

9. How often did home health providers from this agency treat you with courtesy and respect? *
 Always Never

10. Was there ever a need to contact the agency's office to get help of advice, and were they helpful? *
 Yes No

11. Did you have any problems with the care you received through this agency? *
 Yes No
Comment:

12. Would you recommend this agency to your family and friend if they needed home health care? *
 Yes No
Comment:

13. We would like to know your rating of your care from this agency's home health providers. *
 Excellent Average Poor

14. Additional Comments:

Verification: