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ATTENTION: Patient Opinion Survey Dear All Nursing Home Health Services, Inc. Patient: The quality committee at All Nursing Home Health Services, Inc. wants your honest opinion. Please complete this survey and click the submit button. The survey result will assist us in improving the quality of care and services provided by All Nursing Home Health Services, Inc. Thank you for your time and response. Patient Information: First Name: Last Name: Phone Number: Email: Please Indicate How Well We Met Your Expectations In The Areas Listed Below: Written Material Provided: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Explanation of My Therapy: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Assistances in Understanding My Disease Process: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Consideration of My Physical Comfort and Feelings: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Answers to Concerns and Questions During the Admission Process: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Instructions on the Possible Side Effects of Medications: Exceed Expectations Met Expectations Did Not Meet Expectations Not Applicable Please Answer by Selecting 'Yes" or 'No': Were you instructed on how to contact All Nursing Home Health Services, Inc. if you have any questions or problems? Yes No Did you know what to expect concerning home care after being admitted to All Nursing Home Health Services, Inc.? Yes No Would you recommend All Nursing Home Health Services, Inc. to family and/or friends? Yes No Additional Information: What can be done to improve services at All Nursing Home Health Services, Inc.? Other Comments: We appreciated the opportunity to provide home heatlh care to you and look forward to hearing from you. Should you ever wish to speak to us personally, please do not hesitate to call (713) 266-1062.

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