Bay Area Renal Stone Center

6002 49th Street N.
St. Petersburg, FL 33709

1-800-225-ESWL (3795) • 727-521-3929 • Fax 727-527-8362

Home Staff Company Contact Center

Treatment Info

Shock Wave Lithotripsy
(SWL)

Benign Prostatic Hyperplasia (BPH)

FAQs

Glossary

Download Forms

Patient Rights
and Responsibilities

Patient Satisfaction Survey

Medical History
Form

JCAHO Accreditation

Helpful Links

General Questions:
Patient Name (optional)		Treatment Date

Type of Procedure:	Lithotripsy	Number of Stones:
	TUMT
	Other

During Your Treatment:

Were you satisfied with the explanation of the treatment/procedure?

Dissatisfied

Satisfied

How did you feel about the level of care provided by the staff?

Poor

Excellent

Was the billing process explained to your satisfaction?

Poor

Excellent

Did you or your responsible party understand post-treatment instructions after treatment?

Difficult

Easy

Would you return to this facility if retreatment was necessary?

Unlikely

Likely

Following Your Treatment:

To what extent have you been able to return to your daily activities?

None

All

Did you have an elevated temperature over 101 degrees following your treatment?

Yes

If YES, what was your highest recorded temperature?

Rate your pain 48 hours following treatment on a scale from 0 to 10:

How often are you taking medication to relieve pain related to the treatment?

Never

Frequent

Have you made a follow-up appointment with your urologist?

Yes

Did you experience nausea/vomiting after you were discharged?

Yes

Evaluate the overall care you received at this facility:

Poor

Excellent

1 = poor, 2 = unsatisfactory, 3 = satisfactory, 4 = good, 5 = excellent

Comments/Suggestions (including your treatment, our facility & staff, improving patient safety, etc.):

Thank you for completing this survey!