Inpatient Satisfaction Survey Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear Patient,
We hope that we have addressed your health concerns to the best of our abilities. As we strive to improve and upgrade our facilities, a few minutes of your valuable time in answering the questionnaire below will assist us in improving our services. Kindly tick the response which best suits your experience. So help us to help you. Thank you.
Please note that all information relates to the patient.

DBSH/QLTY/PFR/IPSSF/1.3 VER: 04 Effective date: 25/03/2021

1. Registration number *

2. Please state the date of your visit/admission *

YYYY

3. Name (optional)

4. Contact number (optional)

5. Please indicate the name of the doctor that you saw *

6. Age: *

Under 18

19-28

29-38

39-48

49-58

Over 59

7. I think my admission to the hospital was? *

Necessary

Maybe- the doctor knows best

Not necessary

Not sure

8. During this hospital stay how often did the nurses listened to you and answered your calls for help? *

Always

Sometimes

Never

9. During this hospital stay, did the nurses assist you in using the toilet if you asked for assistance? *

Yes

10. During this hospital stay how often did the nurses explain things in a way you could understand? *

Always

Sometimes

Never

11. During this hospital stay how often did the doctors listen carefully to you and explained facts in a way you could understand? *

Always

Sometimes

Never

12. During this hospital stay did the nurses explain to you the reason before giving you any medication? *

Always

Sometimes

Never

13. During this hospital stay did the nurses identify you by name and date of birth before giving you any medication? *

Always

Sometimes

Never

14. The nursing staff was? *

Always helpful

Sometimes helpful

Never helpful

15. The doctor I saw was? *

Always good and understanding

Sometimes good and understanding

Never good and understanding

16. The wards/ICU/Recovery rooms are: *

Extremely good

Good

Not good at all

17. The food provided by the hospital was? *

Always appetizing

Sometimes appetizing

Never appetizing

I did not take food from the hospital

18. If you did not like the food kindly comment on the reason(s) why?

It was not tasty

Too cold

Too salty

Poor presentation-it was not appetizing

Other

Clear selection

19. During the hospital stay did you get information about what symptoms and health problems to look for after you leave the hospital ? *

Always

Sometimes

Never

20. Before you left the hospital did you have a good understanding of the things that you were responsible for in managing your health and medication? *

Yes

21. Would you return to this hospital if you needed medical care? *

Yes

Maybe

22. Using any number from 1 to 5 where 1 is the “worst possible hospital” and 5 is the “best possible hospital”, what number would you use to rate this hospital during your stay? *

23. How did you learn about Dr. Balwant Singh's Hospital Inc.? *

Social Media

Newspaper Ads

Relative/ Friend

24. What can the hospital do to improve?

25. Please feel free to voice any other comments, suggestions and complaints faced by you that are not included in the questions above.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms