Patient Satisfaction Survey

*Please Note: This is not the Health Risk Assessment.

Your responses do not, in any way, impact your health plan coverage or services - anonymous responses are allowed, but may not be reflected in aggregate reporting back to the health plan.

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Name:
Home Address:
Home Phone Number:
Age:
Do you currently have, or have you had in the past year, any of the following health conditions:	Pregnancy Cancer Diabetes Renal Failure Hospitalization for more than 1 night Gastrointestinal Problems Renal Failure or other Kidney Problems Other Catastrophic Health Event or Diagnosis
Who is the employer of the policy holder?
Did you receive any phone calls from a nurse during the past year?	Yes No
If you received a phone call from a nurse did you talk with the nurse or return her call?	Yes No
If you did not speak with a nurse after receiving a call, please describe why:
If you did speak with the nurse, was she polite and courteous?	Yes No
When you spoke with the nurse, was she helpful?	Yes No
When you spoke with the nurse, did you feel she was knowledgable about the subject?	Yes No
Did you receive any information in the mail from a nurse during the past year?	Yes No
If you received information in the mail did you find it helpful?	Yes No
Did you make any changes in your health care, lifestyle, habits, or behaviors as a result of the information you received (either via phone or mail) from the nurse?	Yes No
Do you feel that the nursing services you and your family received benefited you in any way?	Yes No We did not receive any services from a nurse
Do you believe that the services of the nurse did anything to improve the quality of health care you received?	Quality of health care was improved Quality of health care was not impacted Quality of health care was negatively impacted Did not receive the services of a nurse
Do you believe that the services of the nurse impacted the cost of your health care?	Cost of health care was decreased Cost of health care was not impacted Cost of health care was increased Did not receive the services of a nurse
Please list any comments or suggestions that you have pertaining to the nursing services available to you through your health plan:
Would you like for a nurse to call you?	Yes No