QUESTIONNAIRE

Respondents Code:_____

Dear Respondents;

The undersigned is conducting a study entitled CUSTOMER

SATISFACTION IN THE LYING IN IN THE 1ST DISTRICT OF ALBAY, as
part of the requirement for the degree on Masters Of Science in
Public Health.

It is along this line, may I request that you please be one of my

respondents with the assurance that the data that you will be
imparting be used solely for this academic undertaking. Below is
an adapted customer survey form for your pursual.

Thank you,
Respectfully yours,

April Joy Bellen Benavente, RM

Researcher

Name (Optional)__________________________________
Age_____________ Gender ( ) Male ( ) Female
Service Availed
( ) Prenatal
( ) Intra Natal
( ) Post Natal
( ) New Born __ Hearing __ Screening

Please take a few minutes to fill out this survey on the relevance and quality
of service you have received.
INSTRUCTION: PLEASE AS APPROPRIAT OR FILL IN BOX AS
NEEDED.

 1 . On a scale of 0-10, considering your complete experience with our medical facility, how
likely would you be to recommend us to a friend or colleague?
0 1 2 3 4 5 6 7 8 9 10
( ) Very Unlikely ( ) Very Likely
 2. Please state your level of satisfaction with the process of booking an appointment with your
health care provider:
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied

 
3. Please rate your primary healthcare provider in:

Very Satisfied Satisfied Neutral Unsatisfied

Conducting a swift
diagnosis

Prescribing
medications

Pre/intra/post
Natal care

 4. When requesting an appointment, were you given a chance to see your primary provider?
Always
Sometimes
Never

5. How long did you have to wait (past the appointment time) to meet the doctor?
0-30 minutes
30-60 minutes
More than an hour
More than two hours

 6. Is the healthcare facility the one you usually visit in case of a health problem?
Yes
No
 7. Since how many months/years have you been visiting this healthcare facility?
< 6 months
Between 6 months to a year
Minimum 1 year but less than 3 years
Minimum 3 years but less than 5 years
Minimum or more than 5 years

 8 In the past year, how frequently did you visit your healthcare facility?
Not at all
1
2
3
4
5
More than 5 times

 9. On average, how often do you visit the hospital in a given year?
Less than 1 visit
1-2 visits
3-5 visits
More than 5 visits

10. How often did you receive conflicting information from different medical care professionals
at this hospital?
Always
Sometimes
Never

11. Were you informed about the side effects and adverse symptoms of the medicines prescribed
to you?
Yes
No

12. How satisfied were you with the following during your treatment at our medical facility?
Very Satisfied Satisfied Neutral

Professionalism of our staff

 Very Satisfied Satisfied Neutral

Hygiene at the medical center

Care provided by medical personnel
Time that a doctor spent with you
Attentiveness towards concerns
Co-ordination between different departments

13. Were you asked today, if you had seen any health care providers besides us since your last
visit?
Yes
No

14. Do you feel that our work hours are well suited to treat you?
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

15. How convenient is our facility’s location for you?

Somewhat Convenient
Convenient
Neutral
Inconvenient
Somewhat Inconvenient

16. How easy was it to navigate your way across our facility, to your destination with ease?
Very Easy
Easy
Neutral
Difficult
Very Difficult

 
17. How would you rate us on the following parameters?
 Very Good Good Average

Our concern for your privacy and transparency

Quality of service received
Information provided towards leading a healthier life

 18. How easy was it to get a follow-up appointment?

Very Difficult

Difficult

Neutral

Easy

Very Easy