Patient Satisfaction Survey Questionnaire
Patient satisfaction survey questionnaire is primarily intended to gauge how well a patient is satisfied by the services he or she receives in a health facility. The health facilities use the answers given by the respondents to improve the quality of services given. In addition, the data collected during the survey is used to track the quality of service improvement put together by the health facilities over time. Health facilities can also use the same to gauge their performance against the same in other similar facilities. Federal funded health facilities have a more standardized survey form provided for their use by the government.
Patient Satisfaction Survey Form
Pacific____________ Asian__________ American______________
Indian Islander__________White African American_______Hispanic/ Latino ______
Other (specify) ___________
Rate the following services using numbers 1-5 with;
Q1. The ease of accessing medical care in our health facility _________________
Q2. Ability of accessing a qualified medic _________________
Q3. Hour of operation in the health facility _________________
Q4. Convenience of the health facility’s location _________________
Q5. Prompt answering of calls __________
Q6. Time you spend in the facility’s waiting room _________________
Q7. Time spent in the exam room _________________
Q8. The time spent waiting for tests to be conducted _________________
Q9. Time spent waiting for your test results _________________
Q10. The medical provider’s services _________________
Q11. The staff’s willingness to help you _________________
Q12. The neatness and cleanliness of our facility _________________
Q13. Our means of payment _________________
Q14. State any suggestions you may have for our facility’s improvement _________________________________________________________
Thank you for participating in our survey!
Category: Health Questionnaire
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