CHS : Patient Survey


	Question 1 of 8 QUESTION: Courtesy and compassion of the Capital Health System staff was... ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 2 of 8 QUESTION: Degree to which the Capital Health System staff addressed your concerns: ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 3 of 8 QUESTION: Wait time of entire Emergency Room visit was... ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 4 of 8 QUESTION: Your registration process was... ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 5 of 8 QUESTION: The clarity of the discharge instructions you received was... ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 6 of 8 QUESTION: Likelihood of your recommending our Emergency Room to others? ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 7 of 8 QUESTION: Rate your overall satisfaction with the Emergency Room: ANSWERS:* Very Good Good Fair Poor Very Poor Do not remember Question 8 of 8 QUESTION: Do you have any comments? If so please type them in the box below. Comments (optional): Basic Information OPTIONAL FIELDS ARE ONLY REQUIRED IF YOU WISH TO BE CONTACTED BY CAPITAL HEALTH SYSTEM Visit Date: Campus: Name^(optional): Phone #^(optional): () - E-mail^(optional):
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