Hospital Patient Care Improvement Poll
Please help us enhance the quality of our care by sharing your honest feedback about your recent hospital experience.
Please select your age group.
*
Please Select
Under 18
18-30
31-45
46-60
61 and above
What is your gender?
*
Female
Male
Non-binary / Third gender
Prefer not to say
Other
Which hospital department did you visit?
*
Please Select
Emergency
Outpatient
Inpatient
Surgery
Maternity
Pediatrics
Other
Please rate the following aspects of your hospital experience.
*
Rows
Excellent
Good
Average
Poor
Not Applicable
Courtesy and professionalism of staff
1
2
3
4
5
Cleanliness of facilities
6
7
8
9
10
Communication with doctors/nurses
11
12
13
14
15
Timeliness of care
16
17
18
19
20
Comfort of your room/waiting area
21
22
23
24
25
How would you rate your overall satisfaction with the hospital?
*
1
2
3
4
5
Did you feel your concerns and questions were addressed adequately?
*
Yes
Somewhat
No
How likely are you to recommend our hospital to others?
*
Not at all likely
1
2
3
4
5
6
7
8
9
Extremely likely
10
1 is Not at all likely, 10 is Extremely likely
What did you like most about your experience?
What areas do you think we could improve?
Additional comments or suggestions (optional)
Signature (optional)
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