Satisfaction Questionnary
We are very committed to the quality of services (reception, care, accommodation, communication…) we offer.
To enable us to improve them at all times, we will take into consideration the comments that you will be included on this questionnary.
Thank you in advance for your participation.
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| Some informations about you... | |
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| Your opinion about reception... | |
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RECEPTION
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| [Q01] - At your arrival to the clinic
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| [Q02] - On phone
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| [Q03] - At the admissions office
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| [Q04] - At your arrival in the unit
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| [Q05] - At your arrival in the operating theatre
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| Your opinion about human relations... | |
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HUMAN RELATIONS
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| The nursing staff (nurses, midwives, aides, assistants childcare):
| [Q06] - Disponibility
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| [Q07] - Listening
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The psychologist:
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| [Q08] - Accompaniment
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The doctors / surgeons:
| [Q09] - Disponibility
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| [Q10] - Listening
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The anaesthetists:
| [Q11] - Disponibility
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| [Q12] - Listening
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| Your opinion about cares... | |
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CARES
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| [Q13] - Quality of cares
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| [Q14] - Respect of your intimacy
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| [Q15] - Accompaniment by the welfare worker
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| Your opinion about the treatment of pain... | |
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TREATMENT OF PAIN
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Really dissatisfied
| Dissatisfied
| Satisfied
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satisfied
| No opinion
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| [Q16] - Taken care of your pain
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| [Q17] - Degree of relief of your pain
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| Your opinion about delays of taking care... | |
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DELAYS OF TAKING CARE
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Really dissatisfied
| Dissatisfied
| Satisfied
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satisfied
| No opinion
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| [Q18] - At your admission
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| [Q19] - At your arrival in the unit
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| [Q20] - At the discharge office
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| Your opinion about your stay... | |
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STAY
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| Accomodation staff:
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| [Q21] - Politeness
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| [Q22] - Respect of your intimacy
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Room:
| [Q23] - Equipment (bathrooms, furniture)
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| [Q24] - Hygiene, cleanness of places
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Meals :
| [Q25] - Quality of meals
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| [Q26] - Presentation
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| [Q27] - Temperature
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| [Q28] - Did you know the replacement menu
to choose your meals?
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| [Q29] - Do you follow a diet?
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| [Q30] - If so, was it well observed?
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| Your opinion about the quality of delivered information... | |
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QUALITY OF INFORMATION
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| [Q31] - Admission formalities
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| [Q32] - Discharge formalities
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Information about the cost of your pending charges relating to:
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| [Q36] - Information on your health status delivered
by your doctor
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IMPROVEMENT OF INFORMATION
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Very negative
| Negative
| Positive
| Very positive
| No opinion
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| [Q37] - If you have ever been hospitalized at the clinic,
did you notice any changes?
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| Your opinion about all aspects of your stay... | |
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OVERALL ASSESSMENT
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Really dissatisfied
| Dissatisfied
| Satisfied
| Very
satisfied
| No opinion
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| [Q38] - Please give an overall assessment on all aspects
of your stay at the clinic.
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NOTES & SUGGESTIONS
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| Put freely any comments and suggestions in the box opposite.
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| Please, validate the form... | |
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FORM VALIDATION
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| Click the opposite button to validate the form that you've just fill out and submit it to our Quality Department where it will be analyzed for statistical purposes only, in order to improve the quality of our services.
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In keeping with the "IT & Freedom" act n° 78-17 of January 8 1978 relative to information technology, folders and freedom, you have an access and rectification right over all the personal data you leave on this site. Besides, we commit ourselves to taking all the necessary care in preserving the safety of this information, notably in preventing it being deformed, damaged or communicated to third parties. For any request about this, please contact us at: [email protected]
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