A medical negligence questionnaire is a questionnaire which is used to assess the level of negligence or ignorance within medical premises such as a hospital, medical clinic, health facility etc. These questionnaires are put forth patients and are meant to know whether they had to face any kind of medical negligence or not during their experience with the medical centre.

Any such questionnaire has multiple questions and all are directly or indirectly related to knowing about the negligence level so that appropriate actions can be taken. Given below is sample of a medical negligence questionnaire that can be used by any person for the purpose of reference.

Sample Medical Negligence Questionnaire:

Name of patient:

Age of patient:

Gender of patient:

Contact number of patient:

Email address of patient:

Residential address of patient:

Name of hospital wing in which you were admitted:

Name of assigned physician:

Kindly answer all of the given questions in the spaces provided.

Q1. For how long were you admitted in this hospital?

a)      1 day-1 week

b)      1 week-1 month

c)      More than 1 month

Q2. Were you admitted in the general ward or private section?

a)      General ward

b)      Private room

Q3. What medical ailment were you suffering from?


Q4. How many times a day was your condition monitored?

a)      Once

b)      Twice

c)      4 times

d)     More than 4 times

Q5. Were you given sedatives when required?

a)      Yes

b)      No

Q6. Were nurses and visitors asked to wear gloves, masks and shoe bags?

a)      Yes

b)      No

Q7. Was your room or ward clean at all times?

a)      Yes

b)      No

Q8. Were you treated perfectly?

a)      Yes

b)      No

Q9. Do you have any complaint against the hospital?

a)      Yes

b)      No

Q10. If yes, then please register your complaint.