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Western Connecticut Health Network
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Surgery Survey
Thank you for choosing Norwalk Hospital for your surgery. Norwalk Hospital is a member of the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP). We are gathering information on the outcomes of our patients and how they have been feeling since their surgery.
Cycle Number
Case Number
Have you been to a hospital or seen by a doctor for any reason since your surgery?
Yes
No
If you answered NO, you do not need to answer any more questions. If you have answered YES, please answer the following questions.
Have you been seen in an outpatient clinic or doctor’s office after your surgery?
Yes
No
If yes, was this visit for routine follow-up?
Yes
No
If no, what was the reason for your visit?
Date(s) of visit(s)
Have you experienced any health problems since your surgery?
Yes
No
If yes, please explain
Did you go to an Emergency Department (ED) or hospital after your surgery?
Yes
No
Were you admitted?
Yes
No
If yes, please explain
Date(s) of ED visit or hospitalization
Did you have any additional surgery(ies) during this hospitalization?
Yes
No
If yes, what type of surgery(ies) did you have?
Date(s) of surgery(ies)
