Patient Care Quality Assessment
Please help us improve our services by evaluating your recent experience with our patient care team.
Patient Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Unit Visited
*
Please Select
Emergency
Outpatient Clinic
Inpatient Ward
Surgery
Maternity
Pediatrics
Other
Type of Care Received
*
Consultation
Treatment/Procedure
Hospitalization
Other
How would you rate the professionalism of the medical staff?
*
1
2
3
4
5
How would you rate the communication of the healthcare team?
*
1
2
3
4
5
How satisfied were you with the cleanliness and comfort of the facility?
*
Very Unsatisfied
1
2
3
4
Very Satisfied
5
1 is Very Unsatisfied, 5 is Very Satisfied
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I was treated with respect and dignity
1
2
3
4
5
My pain and discomfort were managed appropriately
6
7
8
9
10
Staff responded promptly to my needs
11
12
13
14
15
Was your privacy respected during your care?
*
Yes, always
Most of the time
Sometimes
No
Would you recommend our facility to others?
*
Yes
No
Please provide any additional comments or suggestions to help us improve:
If you would like to be contacted regarding your feedback, please provide your email address:
example@example.com
Submit Assessment
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