Patient Satisfaction Evaluation Sheet
Patient Information
Patient ID | 12345678 |
|---|
Age | 45 |
Gender | Female |
Date of Visit | December 10, 2054 |
1. Overall Satisfaction
Please rate your overall satisfaction with the following aspects of your visit:
Aspect | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
|---|
Overall experience with the healthcare facility | | | | | |
Overall experience with healthcare providers | | | | | |
2. Communication with Healthcare Providers
Rate the communication you experienced with your healthcare providers:
Aspect | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
|---|
Clarity of information provided | | | | | |
Time spent with the healthcare provider | | | | | |
Provider’s ability to listen and address concerns | | | | | |
3. Facility and Environment
Please rate the following aspects of the healthcare facility:
Aspect | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
|---|
Cleanliness and tidiness of the facility | | | | | |
Comfort and convenience of waiting areas | | | | | |
Accessibility and ease of location | | | | | |
4. Timeliness
Rate the following based on your experience:
Aspect | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
|---|
Wait time for appointment | | | | | |
Wait time to be seen by the healthcare provider | | | | | |
5. Staff Interaction
Rate the following based on your experience:
Aspect | Very Satisfied | Satisfied | Neutral | Dissatisfied | Very Dissatisfied |
|---|
Courtesy and professionalism of the staff | | | | | |
Responsiveness of the staff to your needs | | | | | |
6. Overall Rating
Additional Comments:
Thank you for completing this evaluation. Your feedback is valuable in helping us improve the quality of care we provide.
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