Hospital Satisfaction Survey
Patient Information
Patient Name
First Name
Last Name
Birth Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Healthcare Facility
1) Evaluate the following
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Quality
1
2
3
4
Cleanliness
5
6
7
8
Friendliness of Staffs
9
10
11
12
Doctor's Instructions
13
14
15
16
Check-In Process
17
18
19
20
Care for illness
21
22
23
24
Medical Equipment
25
26
27
28
Foods
29
30
31
32
Location
33
34
35
36
2) Rate the communication with the Nurse?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
3) How satisfied are you with the comfort of your room?
1
2
3
4
5
4) Rate the communication with the Doctor?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
5) How many times have you visited the hospital?
0-1 time
1-5 times
5-10 times
10+ times
6) Do you have a health insurance plan?
Yes
No
7) Please rate how satisfied you are with the process of scheduling an appointment with your doctor
Very Satisfied
Somewhat Satisfied
Satisfied
Not Satisfied
8) How long did you have to wait to see the doctor (beyond your scheduled appointment time)?
0-30 minutes
30-60 minutes
More than 60 minutes
9) Are you informed of all of the healthcare services we provide?
Yes
No
10) What else would you like to tell us about?
Submit
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