Patient Satisfaction Survey.
Please take this short survey to let us know whether you were satisfied with the service you received at our hospital
How often do you visit [Medical Facility]?
Once per week or more often
Once every 2 weeks
Once in 1 month
Once in 3 months
Once 6 months
A few times per year
Once per year
Less often than once per year
What services do you usually use at [Medical Facility]?
[Service 1]
[Service 2]
[Service 3]
[Service 4]
[Service 5]
You can use each column only once.
Please indicate your level of agreement with the following statements about [Medical Facility]:
5
Strongly agree
4
3
2
1
Strongly disagree
I was treated with respect
The staff was knowledgeable
My questions and concerns were addressed in a timely manner
The staff provided me with useful referrals and resources
I was provided with the services I needed
[Statement 1]
[Statement 2]
What did you like about our service?
How can we improve our services?
Would you recommend using [Medical Facility] to a friend, relative or colleague?
0 Not at All Likely
1
2
3
4
5 Neutral
6
7
8
9
10 Very Likely
Your gender is:
Male
Female
Please select your age:
Please select one ...
Younger than 18
18-25
26-35
36-45
46-55
56-65
66-75
Older than 75
"Thank you for taking this survey, your feedback is important to us!
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