A patient feedback questionnaire is a very effective method when the treatment provided by the hospitals or nursing homes is to be gauged by the patients. This helps to improve the services that can be provided by these hospitals or medical centres and improve patient care and treatment procedures.

Sample Patient Feedback Questionnaire:

Name of the patient:            _____________________________

Address:                    _____________________________

Age:                          _____________________________

Phone Number:           _____________________________

Email address:                    _____________________________

Name of the hospital:           ______________________________

Name of the doctor:            ______________________________

Q1: Please give your feedback on the way you were treated on your arrival and admission in the hospital

a)   Excellent

b)   Very Good

c)   Good

d)   Fair

e)   Poor

Q2: Were you made aware with all the treatment procedures and the formalities that will be undertaken?

a)   Yes

b)   Not completely

c)   Not at all

Q3: Were your opinions sought before the treatment was started?

a)   Yes

b)   No

c)   I don’t know

Q4: Was the outcome of the treatment clearly explained to you beforehand?

a)   Yes completely

b)   Yes to some extent

c)   No information was given regarding the outcome

Q5: How were your queries and concerns handled by the hospital personnel?

a)   Excellently

b)   Good

c)   Satisfactorily

d)   Not satisfactorily

Q6: Did you trust the doctors, nurses, and assistants would do a good job?

a)   Yes

b)   No

Q7: Please rate the individual attention given on a scale of 1 to 5 where 1 is the lowest and 5 is the highest?

a)   1

b)   2

c)   3

d)   4

e)   5

Q8. How could we have improved the services provided to you?