We Want To Hear From You Date of Service: MM slash DD slash YYYY Hospital or surgery center name: Name of your anesthesiologist: Name of your surgeon: Type of surgery: We aim to provide compassionate, professional and quality care for all of our patients. Did your anesthesiologist meet these attributes? Yes No The preoperative visit is important to us, do you feel your questions were answered to your satisfaction? Yes No Pain control is a high priority for us, do you believe your pain management was acceptable after surgery? Yes No Do you feel your nausea was well controlled following your procedure? Yes No Overall, how would you rate your anesthesiologist? 1 2 3 4 5 How can we improve? Any other feedback?