Care Evaluation Form
NOTE: This form is anonymous. No personal information is collected unless it is specifically included in the text boxes below.
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Table of Contents
Prenatal Care
Labour & Birth Care
Postpartum Care
Informed Choice
General Comments
1. Prenatal Care
*
I received Prenatal Care from Chickadee Maternity Collaborative
Yes
No
Your Prenatal Care Experience
If you did NOT receive prenatal care from Chickadee, please leave blank.
Excellent
Good
Fair
Poor
Number of my prenatal visits
Excellent
Good
Fair
Poor
Length of my prenatal visits
Excellent
Good
Fair
Poor
Scheduling my prenatal visits
Excellent
Good
Fair
Poor
Usefulness of information provided to me for making decisions
Excellent
Good
Fair
Poor
Ease of reaching relevant Primary Care Provider/Registered Nurse
Excellent
Good
Fair
Poor
My confidence in the Primary Care Provider/Registered Nurse's ability
Excellent
Good
Fair
Poor
My comfort in asking questions
Excellent
Good
Fair
Poor
Comments or Suggestions for Improvement to Prenatal Care
If you did NOT receive prenatal care from Chickadee, please leave blank.
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