Date:

Sl no: 1
1. Ease of making appointments by phone.
2. Getting care for illness/injury as soon as you wanted it.
3. Appointment available within a reasonable amount of time
4. Getting after hours care when you needed it
5. The efficiency of the check in process
6. Waiting time in the exam room
7. Waiting time in the reception area
8. Keeping you informed if your appointment time was delayed
9. The courtesy of the person who took your call
10.The friendliness and courtesy of the receptionist
11.The helpfulness of the people nurses/medical staf
12.Your phone calls answered promptly
13.Getting advice or help when needed during office hours
14.Explanation of your procedure(if applicable )
15.Your test results reported in a reasonable amount of time
16.Your visit with the provider(Doctor, physician ,assistant, nurse, practitioner)
17.Willingness to listen carefully to you
18.Explaining things in a way
19.Advice given to you on ways to stay healthy
20.Hours of operation convenient for you
21.Overall comfort
22.Signage and directions easy to follow
23.Our practice
24.Overall rating of care from your provider or nurse
25.Showing care and compassion (Seeming Concerned, Connecting with you on a
human level; not being indiferent or detached
26.It is easy to communicate with the other office staf in the practice
27.The benefit I receive are adequate
28.Answer patient questions thoroughly and Courteously
29.Treat each patient as if he/she were a guest in our homes
30.The staf and the doctors have a friendly and caring attitude toward patient
31.Patients generally are satisfied with this practice
32.The staf is liked by the patients

EYE OUTPATIENT SATISFACTION SURVEY

(For General Information)

Date:

Sl no: 1

Palace:

.
Age:.Nationality:............. Religion:.. Sex:
.
Occupation: (Service/Business/Retired/Others). Patient status: (New/Old). Socio Economic
Status(Rich/Middle Class/Poor) Mode of Payment(Discount for Sr. Citizen/Out of pocket
(Gen))
Visit: (Emergency/Planned)
1. Process of making appointments.
good

Average

Poor

2. Waiting time at registration

good

Average

Poor

3. Waiting time in the reception area

good

Average

Poor

4. The courtesy of the person who took your call/attended you

satisfy

Average

Not satisfy

5. The helpfulness of the people nurses/medical staf

satisfy

Average

Not satisfy

6. Explanation of your procedure(if applicable )

satisfy

Average

Not satisfy

Average

Poor

7. Willingness to listen carefully to you

good

8. Perception of benefit compared to money spent

satisfy

Average

Not satisfy

9. Care by health care personnel

good

Average

Poor

Date:

Sl no: 1
10.Pharmacy services
good

Average

Poor

good

Average

Poor

satisfy

Average

Not satisfy

11.Drinking water facility

12.Sitting facility

13.Facility of Toilet
good

Average

Poor

14.Answer patient questions thoroughly and courteously by the doctors

good

Average

Poor

15.Helping attitude of personnel found at the registration area

Very good

Average

Poor

16.Signage and direction of eye OPD

good

Average

Poor

17.In case of eye OPD, facility of vision arena is

good

Average

Poor

18.In case of eye OPD, facility of reflection arena is

good

Average

Poor

19.In case of eye OPD, facility of doctors check up is

good

Average

Poor

20. Would you like to refer for eye OPD

Always

Reasons for selecting this hospital:

Close to house
Word of mouth

Never

Good communication

Friends/Relatives works here Reasonable price for treatment

Sometimes