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Evaluation
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Evaluation Form
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Evaluation Form
Please take a few minutes to complete this evaluation form. We appreciate your comments and they enable us to improve our services.
Name (optional)
Prenatal Care
Information re: midwifery care at initial visit
Excellent
Very Good
Good
Fair
Poor
Handbook and information sheets
Excellent
Very Good
Good
Fair
Poor
Explanation of tests and procedures
Excellent
Very Good
Good
Fair
Poor
Questions answered with enough information to enable you to make informed decisions?
Excellent
Very Good
Good
Fair
Poor
Emotional support
Excellent
Very Good
Good
Fair
Poor
Communication with midwives
Excellent
Very Good
Good
Fair
Poor
Meeting and spending time with each midwife
Excellent
Very Good
Good
Fair
Poor
Ease of reaching midwives as needed
Excellent
Very Good
Good
Fair
Poor
Consistency in midwives' information
Excellent
Very Good
Good
Fair
Poor
Handbook information
Excellent
Very Good
Good
Fair
Poor
Comments
Labour and Birth Care
Response of midwives to calls or pager
Excellent
Very Good
Good
Fair
Poor
Care and support during labour
Excellent
Very Good
Good
Fair
Poor
Confidence in midwives' ability and support during labour
Excellent
Very Good
Good
Fair
Poor
Communications from midwife especially regarding complications, pain relief etc
Excellent
Very Good
Good
Fair
Poor
Communication/interaction between midwife and other health care providers
Excellent
Very Good
Good
Fair
Poor
Choices & decisions respected by midwives?
Excellent
Very Good
Good
Fair
Poor
Choices & decisions respected by other health care providers (nurses, physicians)?
Excellent
Very Good
Good
Fair
Poor
Experience of birth
Excellent
Very Good
Good
Fair
Poor
Experience for father or baby or partner
Excellent
Very Good
Good
Fair
Poor
Experience immediate postpartum
Excellent
Very Good
Good
Fair
Poor
Comments
Postpartum Care
Support with breastfeeding
Excellent
Very Good
Good
Fair
Poor
Support with baby care
Excellent
Very Good
Good
Fair
Poor
Home visits: time spent by midwife
Excellent
Very Good
Good
Fair
Poor
Ease of reaching midwife via pager or telephone
Excellent
Very Good
Good
Fair
Poor
Effectiveness of help with challenges
Excellent
Very Good
Good
Fair
Poor
Office visits: time spent by midwife
Excellent
Very Good
Good
Fair
Poor
Information re postpartum recovery time
Excellent
Very Good
Good
Fair
Poor
Handbook information
Excellent
Very Good
Good
Fair
Poor
Comments
Group Prenatal and Postnatal Care
Format of Groups
Excellent
Very Good
Good
Fair
Poor
Usefulness of Content discussed
Excellent
Very Good
Good
Fair
Poor
Videos/DVDs shown
Excellent
Very Good
Good
Fair
Poor
Groups Attended
Labour
Breastfeeding
Postpartum
New baby
2 wk PP
4 wk PP
Comments
Practice Environment and Support
Office Reception
Excellent
Very Good
Good
Fair
Poor
Telephone communications
Excellent
Very Good
Good
Fair
Poor
Appointment scheduling
Excellent
Very Good
Good
Fair
Poor
Overall appearance and cleanliness in clinic
Excellent
Very Good
Good
Fair
Poor
Response to messages
Excellent
Very Good
Good
Fair
Poor
Comments
Handbook and Website
Did you find the information relevant?
Excellent
Very Good
Good
Fair
Poor
Did you find the information helpful?
Excellent
Very Good
Good
Fair
Poor
Was the information easy to understand?
Excellent
Very Good
Good
Fair
Poor
Reading the Handbook
Did you read though the handbook once?
Yes
No
Did you refer to it more than once?
Yes
No
Comments
