Care Evaluation Form

NOTE: This form is anonymous. No personal information is collected unless it is specifically included in the text boxes below.

Table of Contents

  1. Prenatal Care
  2. Labour & Birth Care
  3. Postpartum Care
  4. Informed Choice
  5. General Comments

1. Prenatal Care

*I received Prenatal Care from Chickadee Maternity Collaborative

Your Prenatal Care Experience
If you did NOT receive prenatal care from Chickadee, please leave blank.
ExcellentGoodFairPoor
Number of my prenatal visits
Length of my prenatal visits
Scheduling my prenatal visits
Usefulness of information provided to me for making decisions
Ease of reaching relevant Primary Care Provider/Registered Nurse
My confidence in the Primary Care Provider/Registered Nurse's ability
My comfort in asking questions

Comments or Suggestions for Improvement to Prenatal Care
If you did NOT receive prenatal care from Chickadee, please leave blank.