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Thank you for completing this questionnaire. We use your feedback to improve our services.

Background Questions (answer as appropriate)

Patient's first visit here?
Date of Visit:
Please check which of the following procedures you were here for:

A. Admission

Verification of personal information and insurance:
Courtesy of the admitting person:
Admitters ability to assist you with questions or directions (if any):
Rating of pre-admission process (if any):
Comments:

B. Test and Treatments

1. Waiting time for tests or treatments:
2. Concern shown for your comfort during tests or treatments:
3. Courtesy of the person who did your blood draw (if applicable):
4. Courtesy of the person who started the IV (if applicable):
Comments:

C. Accomodations

1. Cleanliness
2. General atmosphere
Comments:

D. Personal Issues

1. Staff concern for your privacy
2. Degree to which hospital staff addressed your emotional needs
3. Response to concerns/complaints made during your visit
Comments:

E. Overall Assessment

1. Overall cheerfulness of the hospital
2. How well staff worked together to care for you
3. Likelihood of your recommending this hospital to others
4. Overall rating of care given at hospital
Comments:
Patient's name (optional):
Telephone number (optional):
Address (optional):