Healthcare Quality Self-Assessment Questionnaire Form
Please complete this self-assessment to help us understand and improve your healthcare quality experience. Your feedback is valuable and will remain confidential.
How would you rate your overall service experience?
*
1
2
3
4
5
How timely was the care or service you received?
*
Very Delayed
1
2
3
4
Very Prompt
5
1 is Very Delayed, 5 is Very Prompt
How would you rate the clarity and helpfulness of communication from staff?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
How clean and comfortable were the facilities?
*
Not Clean
1
2
3
4
Very Clean
5
1 is Not Clean, 5 is Very Clean
How would you rate staff professionalism and courtesy?
*
Unprofessional
1
2
3
4
Extremely Professional
5
1 is Unprofessional, 5 is Extremely Professional
How safe did you feel during your visit?
*
Not Safe
1
2
3
4
Very Safe
5
1 is Not Safe, 5 is Very Safe
How would you describe the follow-up process after your visit?
*
No follow-up
Minimal follow-up
Adequate follow-up
Thorough follow-up
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Staff listened to my concerns
1
2
3
4
5
My privacy was respected
6
7
8
9
10
I understood my care instructions
11
12
13
14
15
How likely are you to recommend this healthcare provider to others?
*
Not Likely
1
2
3
4
Extremely Likely
5
1 is Not Likely, 5 is Extremely Likely
Any additional comments or suggestions? (optional)
Submit Assessment
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