Painless Wellness - Anesthesia Feedback Form

First Name*

Last Name*

Any significant nausea or vomiting on the day of surgery?*

NO

I do NOT remember

Yes, but only mild nausea

Yes, severe nausea but NO vomiting

Yes, severe nausea with vomiting

Did you have a very sore throat MORE than 1-2 days after surgery)?*

No

I do NOT remember

Yes

How was your pain control on the day of surgery?*

I do NOT remember

Well-controlled

Tolerable pain

Pain NOT tolerable at all

How satisfied were you with your overall anesthesia experience?*

Very satisfied

Satisfied

Neither satisfied nor unsatisfied

Unsatisfied

Very unsatisfied

Did you like having a direct phone number to text an anesthesia provider before or after your procedure?*

Yes

No

Does NOT matter to me

Do you think that the Anesthesia Consultation before surgery was worthwhile?*

Yes

No

I was not able to do this before surgery

It does NOT matter to me

Why was the Anesthesia Consult helpful to you?*

Not applicable

Decreased my anxiety

Helped me better understand what to expect

Helped me understand risks and benefits of my future service better

Helped me address concerns or ask questions

Allowed my family member(s) to listen and ask questions too

Seemed less stressful to do ahead of time versus on the day of surgery

Please leave any other issues or feedback for Dr. Cady or your assigned anesthesia provider.

Testimonial for future patients (no names will be shared; only initials)

Email (Optional if you would like a response)