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Patient Feedback Requested – UCLA

Have you been seen at the University of California Los Angeles in the past year for pheo para? Take this short survey about your experience.

Patient Feedback Form

1. Diagnosis:*
- Pheochromocytoma
- Paraganglioma
- Pheo para genetic mutation carrier
- Not yet diagnosed
Indicate all that apply. If you choose, 'not yet diagnosed', the other options cannot be selected.
2. When did you last visit this facility?*
Date Format: MM slash DD slash YYYY

Approximate date is ok.
3. How many times have you visited this facility in the last 12 months?*
4. Which health specialties have you seen at this facility?
- Endocrinologist
- Endocrine/General Surgeon
- ENT
- Urologist
- Genetic Counselor/Geneticist
- Vascular Surgeon
- Head & Neck Surgeon
- Anesthesiologist
- Intensive Care Specialist
- Oncologist
- Cardiologist/Cardiac Surgeon
- Nuclear Medicine Physician
- Radiologist/Radiation Oncologist
- Nephrologist
- Psychologist/Psychiatrist
- Hypertension Specialist
- Pediatrician
- Neurosurgeon
- Intervention Radiologist
- Maternal/Fetal High-Risk Obstetrician
- Palliative Care Specialist
- Other
Check all that apply.
If you selected 'Other' above, please specify which specialties.
5. You were able to schedule appointments in a timely way.*
Provide additional feedback regarding the question above here.
6. Your care by the staff was well coordinated and the health care team worked effectively together (e.g., health care professionals shared information, were aware of your medical history).*
Provide additional feedback regarding the question above here.
7. The facility was easily accessible by car, public transportation, and/or shuttle.*
Provide additional feedback regarding the question above here.
8. The facility communicated with you in your preferred language.*
Provide additional feedback regarding the question above here.
9. The center was accessible, with appropriate accommodations (e.g., ramps, signage)*
Provide additional feedback regarding the question above here.
10. Health care professionals at the facility responded promptly to your questions and concerns.*
Provide additional feedback regarding the question above here.
11. You received explanations that were clear and complete, including descriptions of the risks and benefits of treatment options.*
Provide additional feedback regarding the question above here.
12. Staff were friendly, respectful, and knowledgeable.*
Provide additional feedback regarding the question above here.
13. You had sufficient time to talk with health care professionals and they showed a willingness to listen.*
Provide additional feedback regarding the question above here.
14. You were involved, as much as you wanted to be, in decisions about your care and treatment.*
Provide additional feedback regarding the question above here.
15. If applicable, the facility worked with you regarding insurance coverage and financial obligations (e.g., identified what would be covered by insurance and what would be out-of-pocket expenses; helped to complete insurance forms, offered financial assistance or payment plans, if needed).*
Provide additional feedback regarding the question above here.
16. Less expensive alternatives to treatments, imaging, and prescriptions were discussed with you, if requested and available.*
Provide additional feedback regarding the question above here.
17. The communication between the facility and other health care professionals (including your family doctor and any referrals to specialists) was smooth and timely.*
Provide additional feedback regarding the question above here.
18. The facility provided helpful educational materials.*
19. Would you recommend this facility to another patient?*
20. Is there anything else you would like us to know about the facility?
21. If you have recommendations for how the facility can improve patient care, please share here.
Name
First Last
PROVIDING YOUR NAME AND EMAIL IS ENTIRELY OPTIONAL. By providing your contact information, you agree to allow us to follow up with you regarding your feedback. This information will not be shared with the facility.
Email

Optional
By clicking submit*
I agree.
• To share feedback anonymously with the facility and the Pheo Para Center of Excellence subcommittee for the purpose of consideration of a Center of Excellence/ Clinical Center designation of the facility by the Pheo Para Alliance.
• All of the information provided in this survey is true and correct to the best of my knowledge.
Phone
This field is for validation purposes and should be left unchanged.

Patient Feedback Requested – UCLA

Patient Feedback Form

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