4. Before your surgery, did anyone in this Your Surgeon office give you easy to surgeon’s understand instructions about getting ready 1. Our records show that the surgeon named for your surgery? below performed surgery on you on the date listed below: 1 Yes, definitely 2 Yes, somewhat Name of surgeon label goes here 3 No Date of surgery 5. During your office visits before your Is this right? surgery, did this surgeon tell you there was 1 Yes more than one way to treat your condition? 2 No If No, go to #38 on page 6 1 Yes 2 No The questions in this survey will refer to the surgeon named in Question 1 as “this surgeon.” 6. During your office visits before your Please think of that surgeon as you answer the surgery, did this surgeon ask which way to survey. treat your condition you thought was best for you? Before Your Surgery 1 Yes 2 No 2. Before your surgery, how many office visits did you have with this surgeon? 1 None If None, go to #15 7. During your office visits before your 2 1 visit surgery, did this surgeon talk with you 3 2 visits about the reasons you might want to have 4 3 visits the surgery? 5 4 to 6 visits 1 Not at all 6 7 or more visits 2 A little 3 Some 4 A lot 3. A health provider could be a doctor, nurse, or anyone else you would see for health care. Before your surgery, did 8. During your office visits before your anyone in this office give you all surgeon’s surgery, did this surgeon talk with you the information you needed about your about the reasons you might want to not surgery? have the surgery? 1 Yes, definitely 1 Not at all 2 Yes, somewhat 2 A little 3 No
Your Surgeon 1. Our records show that the surgeon named below performed surgery on you on the date listed below: Name of surgeon label goes here Date of surgery Is this right? 1 Yes 2 No If No, go to #38 on page 6 The questions in this survey will refer to the surgeon named in Question 1 as “this surgeon.” Please think of that surgeon as you answer the survey. Before Your Surgery 2. Before your surgery, how many office visits did you have with this surgeon? 1 None If None, go to #15 2 1 visit 3 2 visits 4 3 visits 5 4 to 6 visits 6 7 or more visits 3. A health provider could be a doctor, nurse, or anyone else you would see for health care. Before your surgery, did anyone in this surgeon’s office give you all the information you needed about your surgery? 1 Yes, definitely 2 Yes, somewhat 3 No 4. Before your surgery, did anyone in this surgeon’s office give you easy to understand instructions about getting ready for your surgery? 1 Yes, definitely 2 Yes, somewhat 3 No 5. During your office visits before your surgery, did this surgeon tell you there was more than one way to treat your condition? 1 Yes 2 No 6. During your office visits before your surgery, did this surgeon ask which way to treat your condition you thought was best for you? 1 Yes 2 No 7. During your office visits before your surgery, did this surgeon talk with you about the reasons you might want to have the surgery? 1 Not at all 2 A little 3 Some 4 A lot 8. During your office visits before your surgery, did this surgeon talk with you about the reasons you might not want to have the surgery? 1 Not at all 2 A little
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