Patient Satisfaction Survey – Vasectomy

East Quay Medical Centre, East Quay, Bridgwater, TA6 4GP
01278 444666
reception.eastquaymc@nhs.net

The information provided will be treated in the STRICTEST CONFIDENCE

Name

If you prefer to be anonymous, please leave blank

Usual GP

Practice

To help us to provide the best vasectomy service possible, feedback from you is essential.

Now that you have had one semen sample clear of sperm, I would be grateful if you would spend a few minutes completing the following questionnaire:

Prior to your procedure
Please rate the following in the range of 1 (poor) to 5 (excellent)
Ease of getting a convenient appointment
12345
Information in your appointment letter
12345
Reception when you arrived at the surgery
12345
The counselling from the Nurse
12345

During your procedure:
Please tick your answers where appropriate
Did the surgeon explain the procedure to you in a manner you understood?
YesNo
Was the follow-up fully explained to you?
YesNo
Was the surgeon approachable?
YesNo
Please give details:

Did the nurse put you at ease?
YesNo
Please give details:

Did you see your GP for any reason arising from the vasectomy?
YesNo
If yes, please give details:

Did you develop a wound infection needing antibiotic treatment?
YesNo
Please rate any pain/discomfort you felt during or soon after the vasectomy; using a scale of pain from 1 (minimal pain) to 5 (severe pain)
During the vasectomy: 12345
Following the vasectomy: 12345

After your procedure
Please rate any problems you had arising after the vasectomy using a scale of 1 (minimal) to 5 (severe)
Bruising: 12345
Bleeding: 12345
Ongoing pain (More than a week after): 12345
Other problems (please specify):

Overall, please rate the vasectomy service, using the scale of 1 (poor) to 5 (excellent)
12345

Any further comments?
Please use the space below for any additional comments you may have about this service and/or any suggestions for improving it.

Thank you for taking the time to complete this questionnaire. Your feedback will be treated confidentially and will help improve services to our patients.