Hospital Feedback Survey Template

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Hospital Feedback Survey
Patient Name:
Date:
Attending Physician:
Case No.:
Reason for Visit:
Performance
Comments
1.
The nurses and staff were patient and accommodating
1
2
3
4
5
2.
The staff dealt with my case in a timely manner
1
2
3
4
5
3.
The doctor listened well
1
2
3
4
5
4.
The doctor asked questions pertaining to my problem
1
2
3
4
5
5.
The doctor outlined all of my options well and thoroughly
1
2
3
4
5
The doctor adequately explained the procedures and
6.
1
2
3
4
5
medications
7.
I felt that I received effective and proper care
1
2
3
4
5
8.
I felt safe and respected
1
2
3
4
5
The medications I received were helpful
9.
1
2
3
4
5
10.
The medications I received had no unexpected side effects
1
2
3
4
5
The hospital was clean
1
2
3
4
5
11.
The staff was knowledgeable and competent
1
2
3
4
5
12.
The doctor was knowledgeable and competent
1
2
3
4
5
13.
I have no major complaints about the hospital
14.
1
2
3
4
5
15.
1
2
3
4
5
16.
1
2
3
4
5
Additional Comments
Comments:
www.FreePrintableMedicalForms.com
Hospital Feedback Survey
Patient Name:
Date:
Attending Physician:
Case No.:
Reason for Visit:
Performance
Comments
1.
The nurses and staff were patient and accommodating
1
2
3
4
5
2.
The staff dealt with my case in a timely manner
1
2
3
4
5
3.
The doctor listened well
1
2
3
4
5
4.
The doctor asked questions pertaining to my problem
1
2
3
4
5
5.
The doctor outlined all of my options well and thoroughly
1
2
3
4
5
The doctor adequately explained the procedures and
6.
1
2
3
4
5
medications
7.
I felt that I received effective and proper care
1
2
3
4
5
8.
I felt safe and respected
1
2
3
4
5
The medications I received were helpful
9.
1
2
3
4
5
10.
The medications I received had no unexpected side effects
1
2
3
4
5
The hospital was clean
1
2
3
4
5
11.
The staff was knowledgeable and competent
1
2
3
4
5
12.
The doctor was knowledgeable and competent
1
2
3
4
5
13.
I have no major complaints about the hospital
14.
1
2
3
4
5
15.
1
2
3
4
5
16.
1
2
3
4
5
Additional Comments
Comments:
www.FreePrintableMedicalForms.com

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