Questionnaire

I) Socio- Economic back ground

a) Name of the patient :

b) Name of the Disease :
c) Gender :
d) Monthly Income of the :
family
e) Educational Qualification :
f) Occupation :
g) Nationality :
h) Residential Address :
i) Size of the family :

II) Awareness of Hospital Services

Are you aware of the other hospitals in the city? Yes No

Are you aware of the Specialty of each hospitals located in the city? Yes No
If yes, state the specialty of the hospitals Known to you? Yes No
Are you aware of the general charges fixed by those hospitals located in the city? Yes No
If yes, express Your Opinion about the charges made by the hospitals in the city? Yes No
Are you aware of any Preventive diseases Program conducted by the hospitals in Yes No
the city?
Are you aware of the Medical Camp Conducted by the Hospitals in the city? Yes No
Are you aware of any Health Magazine? Yes No
Are you aware of the specialty of the hospital Yes No

III) Ranking of major factors that influence behind selection of hospital

1 2 3 4 5
Familiarity with Doctor
Reputation of the Hospital
Inducement by Advertisement
Augmented Facilities
Fees & other expenses
Accessibility
Any other suggestion

IV) Most important person who induces you in selecting a given hospital

1 2 3 4 5
Friends & Family
Neighbours
Colleagues
Any others specify
V) Satisfaction with Hospital Services
Rating of different facilities provided by the hospital on scale of 1-5, with 1 being Lowest & 5 being
Highest

Registration

1 2 3 4 5
Information Provided on Registration
Waiting time in Registration
Formalities in Registration
Approach of the Receptionist
Any other suggestion

Diagnosing

1 2 3 4 5
Time taken in Consultation
Answering the Queries promptly
Counseling by the doctors
Explanation given for aliment
Approach of the doctors
Any others suggestion

Nursing

1 2 3 4 5
Approach of the nurses
Assistance
Instance by the nurses
Medication given by the staff nurses
Availability of the nurses
Any others suggestion

Dietary Services

1 2 3 4 5
Hygienic Conditions of the Canteen
Cost of the food
Quality of the food
Quantity of the food
Taste
Freshness
Room Services
Delivery time
Provision for dietetic food
Staff serving food
Any other suggestion
 Laboratory & Diagnostic Services

1 2 3 4 5
Availability of latest technology
Waiting time
Cost of Services
Time Consumed for report
Response by Staff in-charge
Staff availability
Any other suggestion

Infrastructure

1 2 3 4 5
Availability of the Rooms
Cleanliness of floors
Sanitation of the hospital
Hygienic condition of the rooms
Ventilation of the rooms
Drinking water facility
Provisions for rooms
Provisions for security
Any other suggestion

Availability of medical supplies & other equipment

1 2 3 4 5
Availability of medical store service
Cost of health equipment
Cost of medicine
Quickness in service
Availability of staff
Any other suggestion

Availability of auxiliary services

1 2 3 4 5
Restaurant
ATM
Garden
Recreation facilities like gym, yoga
Internet
Any other suggestion

Payment Problems

1 2 3 4
Lack of Transparency
Unexpected billing
Advance pay
Mode of pay
Any other problem faced
Rank major problems faced by patients (Top 5)

1 2 3 4 5
Waiting time
procedural formalities for registration
Lack of new techniques
Lack of diagnosing amenities
Lack of Infrastructural
Lack of Specialist doctors
Improper diagnosis
High fee & expenses
Any other problems faced

VI) Other Questions

Do you prefer the Membership Schemes in the hospitals Yes No

Are you receiving any Communication from the Hospitals after your Yes No
treatment?
Are you overall satisfied with the Highly satisfied neutral dissatisfied Highly
service satisfied dissatisfied
Would you recommend someone else about us Yes No

VII) Some valuable suggestion for enhancing the services rendered by the hospital