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PATIENT FEEDBACK FORM

We thank you for choosing our hospital for your treatment. We would like to know how much have we been able to
satisfy you, so that we can improve our services further. Please fill this feedback form and hand it in confidence to our
customer care executive.
We urge you to provide the most honest feedback. We have purposefully kept the form anonymous, and assure you
of full confidentiality of the data provided in this form. Thanks.

Date Of Date Of
Admission Discharge

Gender Age
Please rate following questions on a scale of 1 to 5 where, (Check the appropriate box)
5 – Highly Satisfied,
4 – Satisfied,
3 – Nether satisfied nor dissatisfied
2 – Dissatisfied
1 – Highly dissatisfied
NA – Not applicable (Or can’t answer)

No. Questions NA
1 2 3 4 5
A. Your satisfaction with our CLINICAL TREATMENT
1. How satisfied are you with the outcome of your treatment?

2. How satisfied are you with the competence of your doctor?

3. How satisfied are you with the competence of other treatment staff
(Resident doctor, nurses, therapists etc.)

B. Your satisfaction with our BEHAVIOUR towards you


4. How satisfied are you with the behaviour of doctors towards you?

5. How satisfied are you with the behaviour of nurses towards you?

6. Behaviour of front office staff and customer care executives?

7. Behaviour of other staff such as housekeeping and security?

C. Your satisfaction with our PROCESSES


8. How satisfied are you with convenience of our admission process?

9. How satisfied are you with convenience of our discharge process?


10. How satisfied are you with provision of information to you?
11. How satisfied are you with our patient safety processes?
12. How satisfied are you with our other policies and process?
D. Your satisfaction with our SERVICES & FACILITIES
13. How satisfied are you with the housekeeping and cleanliness?
14. How satisfied are you with the maintenance of facilities?
No. Questions NA
1 2 3 4 5
15. How satisfied are you with our security services?
16. How satisfied are you with the comfort of your stay?
17. How satisfied are you with the convenience of your visitors?
18. How satisfied are you with the dietary services provided to you?
E. Your OVERALL satisfaction
19. Please rate your overall satisfaction with the hospital
20. Please indicate how likely are you to recommend our hospital to your friends and relatives for
treatment Very likely Likely Can’t say Not likely Never
21. Please write any other comments/feedback

Date of feedback: