Patient’s feedback form

Annexure 4: QUESTIONNAIRE FOR PATIENT’S FEEDBACK

1. Name of patient (and who is the respondent)

2. Age

3. Sex
a. Male  b. Female 

4. Address

5. Date of interview

6. Since when has he been in the hospital (for inpatients)

7. Occupation
a) Farmer  d) Government employee 
b) Professional  e) Other (please specify)____________
c) Businessman 

8. Income level (per month)

a) Less than 5000 
b) 5000-10000 
c) 10000 and above 

9. Type of
i. Patient a) Inpatient  b) Outpatient 
ii. Treatment a) Medical  b) Surgical 

10. Disease or problem

__________________________________________

11. Dept. visited

12. Doctor

13. Tests undertaken:

a. Radio diagnosis 
b. Laboratory (pathology etc.) 

14. Type of Ward/ Room (for inpatients)

a) General 
b) Special 
c) Semi-special 
d) Deluxe 

i Shree Krishna Hospital

 Patient’s feedback form

e) ICU
i. MICU 
ii. SICU 
iii. SIMC 
iv. PICU 
v. NICU 
(Specify which department the ward falls under)

15. Policy holder

a) Krupa  b) Non-Krupa 

16. Number of visits to Shree Krishna Hospital in the last 6 months__________

Please rate the following:

Completely satisfied (5) Somewhat Satisfied (4) Undecided (3)
Somewhat Dissatisfied (2) Completely Dissatisfied (1)

1. Physician
a) Skill 5 4 3 2 1
b) Courtesy 5 4 3 2 1
c) Punctuality
2. Support staff
a) Nurses 5 4 3 2 1

b) Ward boys 5 4 3 2 1

c) Receptionist 5 4 3 2 1
d) Lab technician 5 4 3 2 1
e) Pharamcy staff 5 4 3 2 1
f) Billing staff/cashier 5 4 3 2 1
g) Any other 5 4 3 2 1
3. Support services
a) Kitchen 5 4 3 2 1
b) Radio-diagnosis 5 4 3 2 1
c) Pathology 5 4 3 2 1
d) Pharmacy 5 4 3 2 1
4. Time spent

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 Patient’s feedback form

a) Diagnosis 5 4 3 2 1
b) Registration 5 4 3 2 1
c) Pharmacy 5 4 3 2 1
d) Cashier counter 5 4 3 2 1
e) Tests (pathology or radio-diagnosis) 5 4 3 2 1
5. Efficiency of treatment 5 4 3 2 1
6. Infrastructure 5 4 3 2 1
7. Convenience 5 4 3 2 1

8. Comfort 5 4 3 2 1
9. Cleanliness
a) Corridors 5 4 3 2 1
b) Waiting room 5 4 3 2 1
c) Bath room 5 4 3 2 1
d) Wards 5 4 3 2 1
10. Expenses
a) Medicine 5 4 3 2 1
b) X-ray 5 4 3 2 1
c) Pathology 5 4 3 2 1
d) Radio-diagnosis 5 4 3 2 1
e) Overall treatment 5 4 3 2 1

11. Procedural 5 4 3 2 1
12. Information dissemination 5 4 3 2 1
13. Grievance Redressal 5 4 3 2 1
14. Emergency services
a) Treatment 5 4 3 2 1
b) Time spent 5 4 3 2 1
c) Information dissemination 5 4 3 2 1

d) Expenses 5 4 3 2 1
15. Overall Medical services 5 4 3 2 1

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 Patient’s feedback form

Complaints and grievances, if any:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

iv Shree Krishna Hospital