TRANSGLOBAL HEALTH SYSTEM INC.

PATIENT SURVEY FORM

Name (optional): ____________________________________ Date: _________________________

Company: ____________________________________
Please check the box of the corresponding rating:
1-Excellent 2 – Very Good 3 – Good 4 – Fair 5 - Poor
Criteria 1 2 3 4 5
PERSONNEL COURTESY & COMPETENCE
1.1 Reception
1.2 Laboratory
1.3 X-Ray
1.4 P.E.
1.5 ECG
1.6 Psychology
1.7 Audio
1.8 Pulmonology
1.9 Dental
2.0 Ultrasound
FACILITIES
Cleanliness of Clinic
Adequacy of Medical Equipment
Space for Waiting Area
MEDICAL EXAMINATION PROCESS
System of Medical Examination
Processing/Waiting Time for Medical Exam
Clarity of Advice on Medical Exam Status
Assistance Provided on Pending Cases(optional)
COMMENTS/SUGGESTIONS:

Form No. REC 10 Issue Date: Sept. 5, 2002 Rev. No. 3 Rev. Date: Apr. 1, 2008

TRANSGLOBAL HEALTH SYSTEM INC.

PATIENT SURVEY FORM

Name (optional): ____________________________________ Date: _________________________

Company: ____________________________________

Please check the box of the corresponding rating:

1-Excellent 2 – Very Good 3 – Good 4 – Fair 5 - Poor
Criteria 1 2 3 4 5
PERSONNEL COURTESY & COMPETENCE
1.1 Reception
1.2 Laboratory
1.3 X-Ray
1.4 P.E.
1.5 ECG
1.6 Psychology
1.7 Audio
1.8 Pulmonology
1.9 Dental
2.0 Ultrasound
FACILITIES
Cleanliness of Clinic
Adequacy of Medical Equipment
Space for Waiting Area
MEDICAL EXAMINATION PROCESS
System of Medical Examination
Processing/Waiting Time for Medical Exam
Clarity of Advice on Medical Exam Status
Assistance Provided on Pending Cases(optional)
COMMENTS/SUGGESTIONS:

Form No. REC 10 Issue Date: Sept. 5, 2002 Rev. No. 3 Rev. Date: Apr. 1, 2008