Post Vasectomy Survey Thank you for having your Vasectomy here at Acorn Surgery. Please complete this short service to help us to continually improve our service. Did you experience any problems booking your vasectomy appointment? Yes No If Yes, please provide more details OptionalDo you feel you were given adequate pre-operative information in the leaflet sent to you? Totally Adequate Fairly Adequate OK Slightly Inadequate Very Inadequate Did you find the discussion before the operation with the Doctor/Nurse useful? Very Useful Fairly Useful OK Poor Useless Did you feel comfortable having this procedure done at this surgery? Completely At Ease Very Comfortable OK Uncomfortable Very Uncomfortable How do you rate the premises and facilities present for todays operation? Excellent Very Good Good Adequate Poor How did you rate the Doctors manner and communication during the operation? Excellent Very Good Good Fair Poor Please rate any pain you felt during the operation No Pain Slightly Painful Painful Very Painful Agony How was the operation in relation to how you expected it to be? Much Better Better As Expected Worse Much Worse What was your overall impression of having your vasectomy undertaken here at Acorn Surgery? Excellent Very Good Good Fair Poor Please feel free to add any further comments about the process of having your vasectomy OptionalName First Last Date of ProcedureDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Comments OptionalThis field is for validation purposes and should be left unchanged.