National Institute for Patient Rights

Protecting and Promoting Patient Rights

Patient Survey Response Form

As part of our ongoing effort to monitor respect for the rights of patients and their families, the National Institute of Patient Rights is conducting a national survey.

Please fill in your responses and share any comments you might have that would help us better understand the quality of your care from the perspective of your rights.

Your answers and comments will be kept in the strictest of confidence in accordance with our strict privacy policy.

If you would like to know how your answers compare with the other participants in the survey enter your email address to receive survey results.

Patient Rights Survey Response Form

The following questions gauge the degree to which providers respected your rights as a patient or advocate.

1. Did you feel your providers involved you in all aspects of the delivery of your care in gaining your informed consent for treatment specific to your lifestyle?

2. Were your providers respectful of your personal, spiritual, cultural, or religious values and beliefs?

3. Did your providers ask you about and respect your advance directive, such as your living will and durable power of attorney for health care?

4. Did someone describe for you realistic care alternatives when hospital care was no longer appropriate?

Comments (please be as specific as possible, but do not use names):

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