Patient
Questionaire
A =excelent
or always B =above
average or often C =average
or sometimes D =below
average or seldom E =failure
or never NA =Not
applicable
Admission
Admitted
through: admitting office
emergency room
L&D
Speed of
admission
A
B
C
D
E
NA
Courtesy
of admission staff
A
B
C
D
NA
EMERGENCY
ROOM
Staff was
attentive
A
B
C
D
NA
Receive
information about medical condition
A
B
C
D
NA
Doctor
arrived on time
A
B
C
D
NA
LABOR AND DELIVERY
Courtesy
of nursing staff
A
B
C
D
NA
Courtesy
of Doctors
A
B
C
D
NA
Cleanliness
of room
A
B
C
D
NA
Overall
delivery experience
A
B
C
D
NA
Anesthesia
Services
A
B
C
D
NA
PATIENT ROOM
Cleanliness
of room
A
B
C
D
NA
Courtesy
shown by housekeeping staff
A
B
C
D
NA
Room temperature
A
B
C
D
NA
Noise level
at night
A
B
C
D
NA
How well room
equipment worked (bed, TV, etc)
A
B
C
D
NA
PATIENT DIET AND MEALS
Temperature
of food (example: cold food cold)
A
B
C
D
NA
Variety
of meals
A
B
C
D
NA
Courtesy
of person(s) who delivered food
A
B
C
D
NA
Timeliness
of meal delivery
A
B
C
D
NA
NURSING CARE
Courtesy
of nursing staff
A
B
C
D
NA
Time it
took nurses to respond to patient needs
A
B
C
D
NA
Confidence
in skill & knowledge of nursing staff
A
B
C
D
NA
Willingness
of nurses to answer my questions
A
B
C
D
NA
Explanation of
how to care for myself when I got home
A
B
C
D
NA
MEDICAL CARE
Doctors
introduced themselves
A
B
C
D
NA
Confidence
in skills & knowledge of doctors
A
B
C
D
NA
Courtesy
of doctors
A
B
C
D
NA
Explanations
of tests and treatments
A
B
C
D
NA
Amount
of time doctors spent with me
A
B
C
D
NA
Willingness
of doctors to answer my questions
A
B
C
D
NA
OTHER HOSPITAL SERVICES
Laboratory
A
B
C
D
NA
Radiology
A
B
C
D
NA
Therapy
Services (physical,
occupational, speech)
A
B
C
D
NA
Patient
Services
A
B
C
D
NA
Social
Services
A
B
C
D
NA
Child Life
Specialists
A
B
C
D
NA
School
teachers
A
B
C
D
NA
Volunteers
A
B
C
D
NA
If you had surgery
before, please complete this section
A =very
good B =good
C =average
D =poor
E =very
poor NA =Not
applicable
Explanation
of risks and benefits of surgery
A
B
C
D
NA
Explanation
of how I would feel after surgery
A
B
C
D
NA
Explanation
of the results of surgery
A
B
C
D
NA
MISCELLANEOUS
If you
had pain, how well was it managed
A
B
C
D
NA
Overall
cleanlinness of hospital
A
B
C
D
NA
Overall
respect for patient privacy
A
B
C
D
NA
Overall
quality of care received
A
B
C
D
NA
VISITOR ACCOMMODATION
Cots
A
B
C
D
NA
Parking
A
B
C
D
NA
Meals
A
B
C
D
NA
GENERAL QUESTIONS
What
was the best part of your hospital stay?
What
would you do to make this hospital a better place?
If
"yes", please explain:
PATIENT INFORMATION
Would you like
someone to call you regarding your comments? If you
would like someone from the hospital to contact you,
please give us your name, address, and day-time telephone
number. If you would like us to contact you via email,
please provide us with your email address.
