Survey Questionnaire Example


Survey questionnaires are used in everyday life for purposes of finding specific information from people concerning a product or a service. These questionnaires are important as they foster accountability and consistency in the society upon evaluation. The respondents give the information seeker an opportunity to know what works in the market and outlines ways of improvement and progress.

An Example of a Patient Survey Questionnaire

Full Name_______________________________________

Address_________________________________________

Gender

Male / Female

Age

Below 21

Between 21-35

Between 35-65

Over 65

Physical Address________________________________________

Postal Address____________________________________________

Type of Patient

Out patient

In patient

Do you have health insurance?

_____________________________________

How are the prices of our health care services?

Cheap

Affordable

Expensive

Very expensive

How often do you attend our Hospital?

Occasionally

Frequently

Often

Rarely

How would you rate the care and service given by the following departments?

Administration

Radiology

Nursing

Laboratory

Surgery

Hospitality

Doctors

Pharmacy

What improvements would you suggest for our Hospital?

_______________________________________________________________

_______________________________________________________________

How is our customer service and health care in general?

________ Excellent

________ Satisfactory

________ Needs improvement

Would you recommend our health care services to your friends and relatives? (Kindly respond with yes / no as appropriate)

______________________________________________

One of our goals is to be a community health care provider. Do you think our health care and facilities are accessible?

_____________________________________________

Kindly explain your answer

________________________________________________________________________

________________________________________________________________________

Our goal is to give quality health care at reasonable and affordable prices. Do you think we have achieved this?

_________________________________________________

What suggestions would you recommend?

________________________________________________________________________

________________________________________________________________________
…………………………………………………………….

Category: Survey Questionnaire

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