Printable Feedback Form

Your Particular
Patient's Name:
Date of Admission:
Date of Discharge:
You were at:	Intensive Care Unit    Ward 3    Ward 5
If you response on behalf, Name:
Address:
Telephone:
E-mail:

Admission
	Delighted	Satisfied	Dissapointed
Explanation by reception
Courtesy
Comment, if any

Nursing Care
Personal care
Prompt service
Explanation
Cheerfulness
Respond to call
Comment, if any

Helpfulness
The nursing staff
The attending Consultant(s)
Comment, if any

Rooms
Cleanliness
Comfort
Facilities
Comment, if any

Foods
Taste
Served warm
Presentation
Comment, if any

Discharge
Process from time informed by doctor
Collection of medicine
Comment, if any

Suggestions for improvement

Printable Feedback Form

Your Particular
Patient's Name:
If you response on behalf, Name:
Address:
Telephone:
E-mail:
Date of Appointment:
Date of Discharge:
Time of Appointment:
Time of Arrival:
You were at:	Accident & Emergency	Eye Centre	Physiotheraphy
	Admission Centre	Heart Centre	Radiology / Imaging
	Cashier Counter	Information Centre	Radiotherapy
	Consultant Suite, L5	Laboratory	Well Being Suite
	Dental Centre	Neuro Centre
	Endoscopy Unit	Pharmacy

Reception Counter
	Delighted	Satisfied	Dissapointed
Attentiveness
Helpfulness
Courtesy
Explanation
Promptness
Waiting Time to be attended by Receptionist	< 5 mins > 10 mins > 20 mins > 30 mins > 40 mins > 60 mins
Comment, if any

Your doctor attending to you
	Delighted	Satisfied	Dissapointed
Attentiveness
Helpfulness
Courtesy
Explanation
Promptness
Waiting time to be attended by Doctor	< 5 mins > 10 mins > 20 mins > 30 mins > 40 mins > 60 mins
Comment, if any

Waiting Time to be attended on Collection of Medicine/ Blood Test/ X-Ray/ Others
	< 5 mins	>10 mins	>20 mins	>30 mins	>40 mins	>60 mins
Pharmacy
Blood Test Department
X-Ray Department
Others (Please specify)
Comment, if any

Suggestions for improvement