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. 2021 Nov 27;57(4):630–636. doi: 10.1016/j.jpedsurg.2021.11.018

Table 1.

Patient's Experience Assessment form survey.

Item Rank
The processes of registration and further activation of the medical file were easy. □ 1      □ 2      □ 3      □ 4      □ 5
I did not face any problems with the registration or login step.The video-call streaming was smooth and I did not face any interruptions. □ 1      □ 2      □ 3      □ 4      □ 5
The time interval from the appointment request till the actual encounter. 1 □ > 6 months, 2 □ ≤ 6 months, 3 □ ≤ 3 month, 4 □ ≤ 1 month, 5 □ ≤ 1 week
I received a reminder message the day before the encounter. □ No (= 1)      □ Yes (= 5)
For me, the appointment was convenient and did not interfere with any of my daily scheduled duties. □ 1      □ 2      □ 3      □ 4      □ 5
I was asked to sign the consent before the video consultation. □ No (= 1)      □ Yes (= 5)
The physician adequately introduced himself to me. □ No (= 1)      □ Yes (= 5)
The physician then verified my identity. □ No (= 1)      □ Yes (= 5)
The physician gave me enough time to describe the case and express my fears and inquiries. □ 1      □ 2      □ 3      □ 4      □ 5
The physician was calm and used clear easily understandable terms during his discussion. □ 1      □ 2      □ 3      □ 4      □ 5
The physician was kind and empathic with me as he listened carefully and paid adequate attention to my concerns. □ 1      □ 2      □ 3      □ 4      □ 5
The physician respected my privacy. □ No (= 1)      □ Yes (= 5)
I have understood and agreed to the management plan. □ No (= 1)      □ Yes (= 5)
I received clear patient education about home medications, wound care, follow-up instructions, and any probable complications. □ 1      □ 2      □ 3      □ 4      □ 5
It was easy to reach the physician to get medical care if postoperative unpleasant events occurred. □ 1      □ 2      □ 3      □ 4      □ 5
The physician was competent, well-trained, and trustworthy. He treated me in a very friendly courteous manner. □ 1      □ 2      □ 3      □ 4      □ 5
Any other concerns such as parking, cleanliness, time in the waiting area, physician or nurse attitude in the clinic, OPD reception office or admission office employees' care and attention. □ 1      □ 2      □ 3      □ 4      □ 5
There was no significant difference between in-person clinic visits and video consultation encounters. □ 1      □ 2      □ 3      □ 4      □ 5
Overall, the service was excellent and it met my expectations. □ 1      □ 2      □ 3      □ 4      □ 5
Do you have any suggestions or comments to improve the service? Free text…….
I recommend this service to the others (as my relative's or friend's kids). □ 1 = Very unlikely, □ 2 = Unlikely,□ 3 = Uncertain, □ 4 = Likely, □ 5 =, Strongly (very likely)

□ 1 = extremely dissatisfied, □ 2 = dissatisfied, □ 3 = uncertain, □ 4 = satisfied, □ 5 =, extremely satisfied