QUESTIONNAIRE FOR PATIENTS

Name:

Gender:

Age:

Income: A. 3000-10000[ ] B.10000-20000[ ]

C.20000-30000[ ] D. Above 30000 [ ]

2. In which hospital you had been hospitalised ?

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3. On what criteria did you choose the hospitals ?

A.doctor [ ] B.service [ ] C.popularity[ ] D.location[ ] E.other specify_________

4. Reason for being hospitalised ?

A.physical injuries [ ] B.psychological problems[ ]

C. Epidemic diseases[ ] D. If other specify______________

5. Mode of payment – A.cash [ ] B.insurance[ ]

C. Cheque[ ] D. if other specify__________

6. Are you satisfied with the amount charge on you ?

A2. Yes[ ] B. No[ ]

7. How do you claim insurance for medical bills ?

A. Directly from hospital[ ] B. Through insurance company [ ]

C. Through agents[ ]
8. Do you have medical card ?

A. Yes[ ] B. No [ ]

If yes, how many times you renew the card in a year

A. Once [ ] B. Twice [ ] C. More than twice [ ] D. Never[ ]

9. Are you satisfied with the services provided by the hospital ?

A. Highly satisfied [ ] B. Satisfied[ ] C.neither satisfied nor dissatisfied[ ]

D. dissatisfied [ ] E.highly dissatisfied [ ]

10. How frequently you go to hospital for routine checkup ?

A. Weekly [ ] B. Mothly [ ] C. Half yearly [ ] D.yearly [ ]

11. Are you satisfied with ambulance services in your area ?

A. Yes[ ] B. No[ ]