Minor Surgery Feedback Your Personal InformationName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Date of Birth DD slash MM slash YYYY During and Before the procedureAre you a patient at Chessington Park Surgery? Yes No If No, please state what surgery you are being referred by? Did you understand how the procedure would be done? Yes No Did you understand why we were doing the procedure? Yes No Were you told about possible complications of the procedure? Yes No How much information about your condition or treatment was given to you Too Much The Right Amount Not Enough (please tell us what you would have liked to know) More Information: OptionalWas the level of pain during the procedure well controlled? Yes Optional No Optional Was the level of pain after the procedure acceptable? Yes Optional No Optional Were there any complications you experienced during the procedure? Yes Optional No Optional Comment on what: Optional More Information: OptionalThe results of the procedureWere you given a leaflet about your procedure or the after effects? Yes No Were you happy with the result of your procedure? Yes No Were you in need of antibiotics after the operation? Yes No If you know why, please explain: Did the wound of your operation site open after the stitches were removed? Yes Optional No Optional On a scale of 1-5 how much has your pain improved (1 being not at all 5 being completely) 1 2 3 4 5 On a scale of 1-5 how would you rate your experience of using this service overall 1 2 3 4 5 Consent I agree to being contacted via the details given above. I agree to the Privacy Policy.Privacy Policy
