Inpatient Hospital Stay Feedback Form
Please provide your feedback about your recent inpatient hospital stay to help us improve our services.
Would you like to provide your name or remain anonymous?
*
I would like to provide my name
I prefer to remain anonymous
Full Name
First Name
Last Name
Ward or Department of Stay
*
Please Select
Surgery
Internal Medicine
Pediatrics
Maternity
Orthopedics
Intensive Care
Other
Admission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of your stay:
*
Rows
Excellent
Good
Fair
Poor
Nursing care
1
2
3
4
Doctor care
5
6
7
8
Cleanliness of the room and facilities
9
10
11
12
Hospital food
13
14
15
16
Staff communication
17
18
19
20
Respect for privacy
21
22
23
24
Noise level during stay
25
26
27
28
Discharge information and instructions
29
30
31
32
How would you rate your overall experience during your hospital stay?
*
1
2
3
4
5
What did you like most about your hospital stay?
What can we improve to make future hospital stays better?
Would you recommend our hospital to others?
*
Yes
No
Not sure
If you would like us to follow up regarding your feedback, please provide your email address (optional):
example@example.com
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