In Office Procedure Satisfaction Survey

At Virginia Beach Obstetrics and Gynecology, our goal is to make your experience with our practice as pleasant as possible. We value your insight with regard to how well we accomplished that goal during your recent office surgery in our surgical suite.



1. Would you like to be contacted by our practice manager?
 Yes No

2. When your surgery was scheduled:
- Were you contacted in a timely manner by the surgery scheduler?
 Yes No N/A
- Was the surgery scheduling done in an efficient manner?
 Yes No
- Do you feel that you were adequately prepared for the procedure, and understood the risks and benefits and expected outcome of the procedure?
 Yes No
- Were all of your questions answered satisfactorily?
 Yes No

3. At the time of your surgery, were you greeted promptly and courteously upon arrival?
 Yes No
- Did you find the waiting time acceptable?
 Yes No

4. Did you find the surgery suite to be acceptable (i.e. comfort, cleanliness, temperature)?
 Yes No

5. Were you greeted appropriately by the nursing staff?
 Yes No
- Did you find that the nurse or medical assistant prepared you for the procedure appropriately (i.e. directing you to the restroom, exam room, etc., instructing you on gowns, drapes, starting your IV, etc.?
 Yes No

6. Did your procedure start on time?
 Yes No

7. Were you satisfied with your postoperative care/recovery?
 Yes No
- Did you find your postoperative instructions to be adequate?
 Yes No
- Did you have any post-op problems or complications (excessive pain, bleeding,
infection, fever)?
 Yes No
--If yes, comment:

8. Overall, are you happy with the outcome of your procedure?
 Yes No

9. Do you feel that your problem was helped or resolved by this procedure?
 Yes No

10. Please rate your pain during the procedure on a scale of 1-10:

11. Please rate your pain 15 minutes to 1 hour after the procedure on a scale of 1-10:

12. Please rate your pain on the 12 hours following your procedure on a scale of 1-10:

13. Please rate your pain on the 24th hour after your procedure on a scale of 1-10:

14. Please rate your overall experience on a scale of 1-10:

15. Would you do this procedure again in-office at the Virginia Beach OB/GYN if surgery were needed?
 Yes No

16. Do you have any additional comments, questions or feedback?

17. Do we have permission to reproduce all or a portion of your comments on our website as a patient testimonial?
- If you answer yes, only your first name and last initial will be used. Thank you.
 Yes No