Satisfaction questionnaire example

Questionnaire for older patients in the hospitals about their satisfaction to their admission experience

1. Initials:  _______

2. Medical record number:  ___________________

3. Gender:    1. Male

                    2. Female

                     3. Other

4. Date of birth (MM/DD/YYYY):  ___ / ___  / _______

5. Highest education:       1. Elementary school or uneducated

                               2. Junior high school or high school

                                         3. College or university

6. Employment status:     1. Employed

                                         2. Unemployed

7. Marital status:              1. Single

                                         2. Married or living together

                                         3. Widowed or divorced

8. Distance to hospital:    1. Less than 5 km

                                         2. 5-10 km

                                         3. More than 10 km

9. Transport to hospital:   1. On foot or Bicycle

                                         2. Taxi or private car or motorcycle

                                         3. Public transport (bus/MRT)

                                         5. Ambulance

10. Health insurance:       1. Government-funded insurance

                                         2. Private insurance

                                          3. Without insurance

 

Hospital visit

11. Is this your first visit (both for inpatient and outpatient setting) to this hospital?   1. Yes [ GO TO No. 13 ]                                

2. No

12. Do you ever admitted in this hospital in the last 12 months?

          1. Yes, once

          2. Yes, twice or more

          3. No, only outpatient visit

13. Why do you choose this hospital?

          1. Mandatory by the health insurance

          2. Convinience

          3. Other:  ______________________

14. Do you ever admitted in another hospital(s) in the last 12 months?

          1. Yes, once

          2. Yes, twice or more

          3. No, only outpatient visit

          4. Never

 

Staff
No	Statement	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
15.1	Availability
15.2	Explain clearly
15.3	Dress professionally
15.4	Showing emphaty
15.5	Overall

 

Information
No	Statement	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
16.1	Clear terms and conditions document
16.2	Option to choose preferred doctor
16.3	Explanation about basic procedures
16.4	Overall

 

Time
No	Statement	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
17.1	Waiting time to meet admission staff
17.2	Total time spent for admission process
17.3	Overall

 

Finance
No	Statement	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
18.1	Clear basic tariff of health care provided
18.2	Cost spent for admission process
18.3	Overall

 

General experience
No	Statement	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
19	Overall admission process

 

20. Is there any suggestion to improve your next experience?

          ___________________________________________

          ___________________________________________

          ___________________________________________