IPD Patient Feedback Form
We are committed to providing safe, compassionate, and high-quality healthcare. Your valuable feedback helps us improve our services. This form will take approximately 3–5 minutes to complete.
Patient Information
Patient Name
Mobile Number
Gender
Please Select
Male
Female
Other
Consulting Doctor Name
Admission Date
-
Month
-
Day
Year
Date
Room Number
Admission Process
1. Were admission procedures explained clearly and behavior of staff ?
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Doctor Care
2. Did the doctor explain your medical condition clearly?
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
3. Was the doctor available when required?
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
4. Overall satisfaction with the doctor's care
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Nursing Care
5. Behavior of nursing staff and responding to calls
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
6. Explanation before procedures or medications
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
7. Overall nursing care
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Hospital Facilities
8. Room ,Washroom cleanliness and overall hygiene
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
9. Bed comfort
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
10. Safety and security
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Food Services (If Applicable)
11. Quality of food
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
12. Timely meal service
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
13. Dietitian guidance (if provided)
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Pharmacy
14. Availability of prescribed medicines
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
15. Pharmacy staff behavior
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Laboratory & Diagnostics
16. Lab Billing Staff Behavior
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
17. Staff professionalism
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
18. Timely availability of reports
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Billing & Discharge
19. Billing process
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
20. Transparency of hospital charges
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
21. Discharge process
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Overall Experience
22. Overall satisfaction with your hospital stay
*
Bad
1
2
3
4
5
6
7
8
9
V-Very Good
10
1 is Bad , 10 is V-Very Good
Recommendation Score (NPS)
23. How likely are you to recommend Sapra Multispeciality Hospital to your family and friends?
*
Not Likely
1
2
3
4
5
6
7
8
9
Extremely Likely
10
1 is Not Likely, 10 is Extremely Likely
Your Feedback
24. What impressed you the most during your stay?
25. Which staff member provided exceptional service? (Optional)
26. What can we improve?
27. Which department or service was the issue related to? (Select all that apply)
Please Select
Admission & Registration
Doctor / Medical Care
Nursing Care
Housekeeping & Cleanliness
Food & Dietary Services
Pharmacy
Laboratory / Diagnostics
Billing & Insurance
Room Facilities & Maintenance
Discharge Process
Security
Reception / Front Desk
Patient Relations
Other (Please Specify)
28. Please describe the issue in detail.
29. How would you like us to resolve your concern? (Optional)
30. Would you like our Patient Relations Team to contact you regarding this issue?
Yes
No
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