In the last 12 months, were you as involved as much as you wanted in choosing the In general, how would you rate treatment for kidney disease that your overall health? is right for you? 1 Excellent 1 Yes 2 Very good 2 No 3 Good 4 Fair In the last 12 months, were you 5 Poor ever unhappy with the care you received at the dialysis center or In general, how would you rate from your kidney doctors? your overall mental or emotional 1 Yes health? 2 No If No, Go to Question 45 1 Excellent 2 Very good In the last 12 months, did you 3 Good ever talk to someone on the 4 Fair dialysis center staff about this? 5 Poor 1 Yes 2 No If No, Go to Question 45 Are you being treated for high blood pressure? In the last 12 months, how often 1 Yes were you satisfied with the way 2 No they handled these problems? 1 Never Are you being treated for 2 Sometimes diabetes or high blood sugar? 3 Usually 1 Yes 4 Always 2 No Medicare and your State have Are you being treated for heart special agencies that check the disease or heart problems? quality of care at this dialysis 1 Yes center. In the last 12 months, did 2 No you make a complaint to any of these agencies? Are you deaf or do you have 1 Yes serious difficulty hearing? 2 No 1 Yes 2 No
In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you? 1 Yes 2 No In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, did you ever talk to someone on the dialysis center staff about this? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, how often were you satisfied with the way they handled these problems? 1 Never 2 Sometimes 3 Usually 4 Always Medicare and your State have special agencies that check the quality of care at this dialysis center. In the last 12 months, did you make a complaint to any of these agencies? 1 Yes 2 No In general, how would you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor In general, how would you rate your overall mental or emotional health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Are you being treated for high blood pressure? 1 Yes 2 No Are you being treated for diabetes or high blood sugar? 1 Yes 2 No Are you being treated for heart disease or heart problems? 1 Yes 2 No Are you deaf or do you have serious difficulty hearing? 1 Yes 2 No
ICH_SurveyStandard_English.docx