Children’s Surgical Survey
Thank you for choosing Children’s Healthcare of Atlanta for your child’s care. Your child recently had a surgical procedure. We are interested in how your child is feeling since his surgery. The Department of Surgery at our hospital is a member of the American College of Surgeons’ Pediatric National Surgical Quality Improvement Program. We are gathering information on the health and outcomes of our patients after surgery. Your child’s health and your feedback are important to us. Please take a few minutes to answer the questions below. Click submit after you have completed the form. Your and your child’s identity will be kept confidential. We greatly appreciate your feedback.
Patient's name
*
First Name
Last Name
Has your child been to a hospital or been seen by a doctor for any reason since their surgery?
*
Yes
No
Was your child seen in an outpatient clinic or doctor’s office after their surgery?
Yes
No
Was this visit for a routine follow-up?
Yes
No
Explain:
Date of visit
-
Month
-
Day
Year
Date
Has your child experienced any health problems since their surgery?
Yes
No
Explain:
Did your child go to an emergency department or hospital after their surgery?
Yes
No
Was your child admitted?
Yes
No
If yes, explain:
Date(s) of emergency department visit or hospitalization?
Did your child have any additional surgery(ies) during this hospitalization?
Yes
No
What type of surgery(ies) were performed?
Date(s) of surgeries?
Submit
Should be Empty: