Patient Feedback Form
When a health institution wants to gauge its quality of service to its clients, getting to know how they feel about the services they get from the institution is the best way to find out. Patients are the best people to question, using a patient feedback form that seeks to know what exactly they need to know about their services.
Name of patient: ___________________________________________________________________
Address: __________________________________________________________________________
Contacts: __________________________________________________________________________
Date admitted: ______________________________________________________________________
Date of discharge: ___________________________________________________________________
Key
A) Above par B) Proper C) Satisfactory D) Fair
How would you rate the time it took before you were attended to? ______________________________
When they got round to attending to you, did you get the necessary services? __________. And how were they? _________________________________________________________________________
When you were admitted would how would you rate the cleanliness, service, condition of the health facility? ___________________________________________________________________________
Assuming you have been to others as a patient or visitor, how does it compare to other health facilities that you have been to? ________________________________________________________________
How does the quality of service, availability of assistance and attention to detail compare the charges? ___________________________________________________________________________________
In a nutshell how would you summarize the attitude of doctors and nurses? _____________________
Would you want to be brought to the hospital if you ever fell ill again? __________________________
Would you advise anyone in need of medical assistance to come here? __________________________
What impressed you most about the facility and what are your sentiments? ____________________ ___________________________________________________________________________________
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