In-Patient Feedback

Patient’s Details

Name *

Phone

Your care from Nurses

Treated Respectfully *

• Always
• Mostly
• Sometimes
• Never

Care & Concern *

• Always
• Mostly
• Sometimes
• Never

Information & Explanation of Patient Condition/Procedure *

• Always
• Mostly
• Sometimes
• Never

Your care from Doctors

Treated Respectfully *

• Always
• Mostly
• Sometimes
• Never

Care & Concerned *

• Always
• Mostly
• Sometimes
• Never

Information & Explanation of Patient Condition/Procedure *

• Always
• Mostly
• Sometimes
• Never

Were you able to discuss your worries or concerns with the doctors? *

• Always
• Mostly
• Sometimes
• Never

Food Services

Timely Food Served *

• Always
• Mostly
• Sometimes
• Never

Food served as per Diet Chart *

• Always
• Mostly
• Sometimes
• Never

Right food taste *

• Always
• Mostly
• Sometimes
• Never

Acceptable temperature of food *

• Always
• Mostly
• Sometimes
• Never

Environment & Facilities

Cleanliness of room & toilet *

• Always
• Mostly
• Sometimes
• Never

Quietness of surroundings *

• Always
• Mostly
• Sometimes
• Never

Your opinion about Square Hospital:

Your opinion about Square Hospital: *

• Excellent
• Good
• Satisfactory
• Poor

Would you recommend this hospital to your friends and family?

Your opinion about Square Hospital: (copy) *

• Excellent
• Good
• Satisfactory
• Poor

Submit

In-Patient Feedback

Patient’s Details

Name *

Phone

Your care from Nurses

Treated Respectfully *

• Always
• Mostly
• Sometimes
• Never

Care & Concern *

• Always
• Mostly
• Sometimes
• Never

Information & Explanation of Patient Condition/Procedure *

• Always
• Mostly
• Sometimes
• Never

Your care from Doctors

Treated Respectfully *

• Always
• Mostly
• Sometimes
• Never

Care & Concerned *

• Always
• Mostly
• Sometimes
• Never

Information & Explanation of Patient Condition/Procedure *

• Always
• Mostly
• Sometimes
• Never

Were you able to discuss your worries or concerns with the doctors? *

• Always
• Mostly
• Sometimes
• Never

Food Services

Timely Food Served *

• Always
• Mostly
• Sometimes
• Never

Food served as per Diet Chart *

• Always
• Mostly
• Sometimes
• Never

Right food taste *

• Always
• Mostly
• Sometimes
• Never

Acceptable temperature of food *

• Always
• Mostly
• Sometimes
• Never

Environment & Facilities

Cleanliness of room & toilet *

• Always
• Mostly
• Sometimes
• Never

Quietness of surroundings *

• Always
• Mostly
• Sometimes
• Never

Your opinion about Square Hospital:

Your opinion about Square Hospital: *

• Excellent
• Good
• Satisfactory
• Poor

Would you recommend this hospital to your friends and family?

Your opinion about Square Hospital: (copy) *

• Excellent
• Good
• Satisfactory
• Poor

Submit