Quality Home Health, Inc.

PostCare Survey

If you have already received care from Quality Home Health,
we would like you to answer these questions about our services.

[Please take our PreCare Survey, if you have never
used Quality Home Health before.]

1. Did you receive home care services for (check one):

Less than 1 month
1 to 3 months
3 to 6 months
6 months to 1 year
Greater than 1 year

2. I felt the number of visits made was:

3. My questions and concerns were answered promptly and politely:

Yes No

4. I was given all the information I needed to manage my care at home before being discharged from Quality Home Health:

Yes No

5. The financial arrangements were handled in a satisfactory manner:

Yes No

6. QUALITY OF CARE:
(please rate the services you received)

7. ATTITUDE:
(please rate the services you received)

8. OVERALL SERVICE:
(please rate our OVERALL service)

	3	2	1	N/A
OVERALL SERVICE

9. I would contact QHH if I needed home care again:

Yes No

10. Have you shared with your physician your feelings about our agency and the care you received?

Yes No
Positive Negative
If negative, what was the problem?

11. Did you receive equipment or supplies?

Yes No
If yes, who was your supplier?
Were you pleased with your supplier? Yes No

12. Is there anyone you can think of now who might be in need of our assistance?

Name:
Phone:

13. How were you referred to our agency?

Doctor
Hospital
Nursing Home
Friend/ Relative

14. Comments:

Quality Home Health | 519 N. Franklin St., Ste 203 | Morris, IL 60450
(815) 942-1256 | Fax (815) 942-5203

Website Design by ProMediAspire