Flexible Bronchoscopy Service Evaluation

Flexible Bronchoscopy Service Evaluation

At Alder Hey Children's Hospital
This section is to be filled out by the parent/carer of the child.

We would like you to think about your recent experience at Alder Hey Children's Hopsital and answer a few short questions about your time with us.
Date of your child's bronchoscopy

DayMonthYear
Date you are completing this form

DayMonthYear
Just a little bit of information about you...
What is your ethnic background?
What is your relationship to the child?

MotherFatherGrandparentGuardianOther
Now, just a little bit of information about your child...
How old is your child?

0-5 years old6-10 years old11-15 years old16+ years old
Is your child a girl or a boy?

GirlBoy
Please tick the most appropriate box.

Extremely likelyLikelyNeither likely nor unlikelyUnlikelyExtremely unlikelyI don't know
Can you give a reason for your above answer?
We are always trying to improve our service and ensure that patients and their families have the best experience possible.

Please help us improve our services by answering the following questions...
What do you think we did well?
What do you think we can improve on?
Is there anything else you would like to comment on about your experience with us?
The next few questions are about any side effects or symptoms your child may have experienced following the bronchoscopy.
Did your child experience any of the following symptoms in the 12 hours following the procedure?

BreathlessnessCoughingSore throatHoarse voiceFeeling sickHigh temperatureNone of these
Did your child experience any other symptoms in the 12 hours following the procedure? If so, please give details.
If your child experienced any symptoms, did they affect your child's usual activities in any way? If yes, please give details.
If your child experienced any symptoms, when was he/she back to normal?
Thank you for taking the time to complete our survey!

Now, please could you ask your child to fill out the next section as independently as possible.
This section is to be filled out by the child.
YesMaybeNoDon't know
Please explain in your own words.
What could we do better if you ever have to come back to us again?
How have you been feeling since your visit to hospital?
If you have been feeling poorly, please tick how you have felt.

I haven't felt poorlyMy throat hurtsI have been struggling to catch my breathMy voice sounds funnyI have been feeling sickI have been coughingI have been shiveringI have felt poorly in a different way
Should be Empty: