Information for patients Clinic/Ward of Hospitalization* Admission Emergency Scheduled Date of visit* DD dash MM dash YYYY Doctor Showed real interest*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEInspired confidence*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEGave clear and understandable instructions*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREESpend adequate time on my health problem*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEWas polite*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREE Nurse Showed real interest*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEGave clear and understandable instructions*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEWas polite*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREE Secretary Complete the procedures without delays*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEHe was effective*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEWas polite*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREE General I agree to the compliance of visiting hours*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEClinic areas were clean*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEMeal quality was satisfactory*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREEI would recommend the hospital to a third party*TOTALLY DISAGREERATHER DISAGREENEITHER AGREE OR DISAGREERATHER AGREETOTALLY AGREE Required Optional Gender* Man Woman Name Age* 18-30 31-50 51-70 70+ Last name Education level* Primary education Secondary Education Higher education PhonePhoneThis field is for validation purposes and should be left unchanged.
