Patient Follow-up

Patient Follow-up Survey

Mammoth Medical Missions

Today’s Date

–Month –Day Year
Full Name*

First Name Last Name
E-mail*
Address

Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
Where were you treated by Mammoth Medical Missions?*
How long ago were you treated by Mammoth Medical Missions? Choose the closest time.

3 months 6 months 1 year 2 years
If trauma, what part of you was injured?
If multiple areas injured, please select what part of you was injured.
If Other, please specify what was injured.
How were you injured?
If traumatic, how was your injury treated?
If Other, please specify treatment.
If surgery or procedure for non-traumatic injury was performed, please specify type.
If Other, please specify surgery.
How long had you had the problem that MMM treated you for?

hours days weeks months years
If you returned to see the medical team again, what did they do?
Did you see other health care providers after the medical team left?

Yes
No
If yes, what did they do for you?
Other treatment required?
When was other treatment required?
Do you still require care for the same injury/ailment? Please specify what you need done or see health care providers for?
Did you understand what was wrong with you and how the medical team was going to help you?

1 2 3 4 5 6 7

NO understanding Complete understanding
Do you believe the procedures the medical team performed on you helped?

1 2 3 4 5 6 7

Much Worse Much Better
Did the translators help you understand what was needed and going to happen?

1 2 3 4 5 6 7

DID NOT help Really helped me understand
Did you feel the medical team cared about you, treated you well and were compassionate?

1 2 3 4 5 6 7

Didn’t care Cared/kind/compassionate
Was your pain treated adequately?

1 2 3 4 5 6 7

Worst Pain Ever NO pain at all
Would you let these doctors treat you again?

1 2 3 4 5 6 7

NEVER 100% YES
Do you believe these doctors did the best they could given the equipment, situation etc

1 2 3 4 5 6 7

NO YES
Are you better off now than before they treated you?

1 2 3 4 5 6 7

NO YES
How is your function, ability to work, activities of daily living as compared to before your treatment?

1 2 3 4 5 6 7

Much worse normal
Do you have any questions, comments or suggestions for the Mammoth Medical Missions Team?
Enter the message as it’s shown*

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