MHC Patient Satisfaction Survey
It can be filled out by the patient or their family/representatives. The final results will assist us in determining which of our services of the Monthly Health Check require improvement. The data collected from this survey will be analyzed as a group to ensure confidentiality and anonymity. No personal identifiable information will be shared.
Please rate how satisfied are you with the following statements
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
N/A
the overall care you received from the Monthly Health Check Team?
the courtesy of the receptionist?
the time the health care provider spent with you during visit/consultation?
the care received by you from the registered nurses?
the support that was provided by the entire HENM team?
by the nurses?
by the provider?
the information were given to you about your vitals?
the provider understood your health concerns?
your involvement in decisions about their care?
the timeliness of the service?
the cleanliness of the facility?
the level of noise?
the temperature of the facility?
the convenience of the location of the Monthly Health Check?
the thoroughness of your health screening?
care plan was clear and easy to follow?
the observance of your wishes?
Overall, please rate the Monthly Health Check screening.
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
If you have anything you think should be done differently, please write below
Are you willing to be screened next month?
Yes
No
Were you pleased with the services you recieved?
Yes
No
Will you follow the advice given by the Provider?
Yes
No
What zip code area do you live in?
What is your age group?
Less than 20 year
61 to 80 years
21 to 40 years
81 years and over
41 to 60 years
Rather not say
Gender
Female
Male
Don't want to specify
Other
Do you have
Public Insurance
Private Insurance
In between Insurances
No Insurance
Other
Do you have a Provider?
Yes
No
Name (Optional)
First Name
Last Name
Submit
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