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Hospital Patient Survey
Please take a few moments to complete this survey
1
Step 1
2
Step 2
Name:
This field is required.Please enter value
Ward/IP Number:
This field is required.Please enter value
Gender:
Male
Female
This field is required.Please enter value
Date of Birth:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Email:
This field is required.Please enter value
Please enter valid email address
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Was this your first time as a patient at "hospital"?:
Yes
No
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How many days were you in the hospital?:
1-3 days
4-6 days
7+ days
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How did you select "hospital"?:
My doctor recommended
It was my own choice
I came through emergency dept
Other
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What type of unit were you in for most of your stay?:
Maternity
General
Surgical
Intensive
Rehabilitation
Pediatric
Children's
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What is the specialty of the doctor who admitted you to this hospital?:
General / Internal
Pediatrician
Gynecologist
Ear, Nose, Throat
General Surgery
Neurosurgery
Urology
Orthopedic
Cancer / Tumor
Others
This field is required.Please enter value
Next
Rate the following statements concerning "hospital":
Agree
Disagree
Highest quality doctor staff in the area
Highest quality nursing staff in the area
Most up-to-date medical equipment
Most up-to-date facilities in the area
My doctors were skilled and experienced
My doctor was kind and caring
My doctor kept me fully informed
Tests and procedures were completely explained to me
The nurses were skilled in the treatment provided me
The nurses were responsive when I called
What is your overall satisfaction with [HOSPITAL] and the medical care you received?:
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Please comment on your experience as a patient of "hospital":
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