Jekim Hospital Patient Feedback Form

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Date of visit
DATE
Month
Day
Year
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Please select your patient type* This field is required.
Outpatient
Inpatient
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Which department or service did you visit?* This field is required.
Please Select
Please Select
General Medicine
Surgery
Pediatrics
Orthopedics
Maternity Gynecology
Emergency
Consultation
Pharmacy
It/insurance
Minor Theatre
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Please rate the following aspects of your visit* This field is required.
Very Poor
Poor
Average
Good
Excellent
Cleanliness
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Staff professionalism
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Waiting time
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Communication
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Comfort of facilities
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Ease of appointment/registration
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Nurses and Doctors care
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Dieting and Foods
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Cleanliness
Staff professionalism
Waiting time
Communication
Comfort of facilities
Ease of appointment/registration
Nurses and Doctors care
Dieting and Foods
Very Poor
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Poor
Row 0, Column 1
Average
Row 0, Column 2
Good
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Excellent
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Very Poor
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Poor
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Average
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Good
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Excellent
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Very Poor
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Poor
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Average
Row 2, Column 2
Good
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Excellent
Row 2, Column 4
Very Poor
Row 3, Column 0
Poor
Row 3, Column 1
Average
Row 3, Column 2
Good
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Excellent
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Very Poor
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Poor
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Average
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Good
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Excellent
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Very Poor
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Poor
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Average
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Good
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Excellent
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Very Poor
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Poor
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Average
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Good
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Excellent
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Very Poor
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Poor
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Average
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Good
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Excellent
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If poor or average, Kindly give us the reasons/gaps you experienced
6
How would you rate your overall experience?* This field is required.
1
2
3
4
5
Worst
Best
7
Please share any additional comments or suggestions
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