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Questionnaire for assessing the level of Patient Satisfaction of indoor and outdoor patients (to be
administered to the inpatients who have been discharged from the hospital, before they leave the
premises, and on outpatients after they have been treated at the OPDs.)
General Information:
2. Age
3. Sex
4. Address
5. Date of interview
7. Occupation
a) Farmer d) Government employee
b) Professional e) Other (please specify)____________
c) Businessman
9. Type of
i. Patient a) Inpatient b) Outpatient
ii. Treatment a) Medical b) Surgical
12. Doctor
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c) Semi-special
d) Deluxe
e) ICU
i. MICU
ii. SICU
iii. SIMC
iv. PICU
v. NICU
(Specify which department the ward falls under)
17. Which was the first point of contact when you entered the hospital?
a) Reception counter
b) Krupa desk
c) Security Personnel
d) Registration Counter
e) Social worker
f) Other (please specify)
19. Did you avail of any freeship facilities provided by the hospital?
a) Yes b) No
If yes please specify what kind and how much__________________________
_______________________________________________________________
21. Have you taken any mediclaim facilities? If yes specify which kind_________
__________________________________________________________________
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22. Rate the following factors on the scale in choosing a hospital.
1) Services Provided 5 4 3 2 1
2) Location 5 4 3 2 1
3) Expert Referrals 5 4 3 2 1
4) Word of mouth 5 4 3 2 1
5) Historical association 5 4 3 2 1
6) Reputation 5 4 3 2 1
9) Convenience 5 4 3 2 1
12) Advertisement 5 4 3 2 1
13) Discount/freeship 5 4 3 2 1
15) Aesthetics 5 4 3 2 1
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Please rate the following:
Completely satisfied (5) Somewhat Satisfied (4) Undecided (3)
Somewhat Dissatisfied (2) Completely Dissatisfied (1)
___________________________________________________________________________
1. Information pertaining to patient’s rating of the hospital as a whole:
1. Location 5 4 3 2 1
2. Infrastructure 5 4 3 2 1
3. Facilities 5 4 3 2 1
4. Technology 5 4 3 2 1
5. Cleanliness of
a. Corridors 5 4 3 2 1
b. Bathrooms 5 4 3 2 1
c. Ward in general 5 4 3 2 1
d. For inpatients: Bedsheets 5 4 3 2 1
(including regularity of changing)
6. Layout (Maternity –Pediatric, 5 4 3 2 1
location of testing depts., (ultrasound-bathroom etc)
7. Comfort of surroundings 5 4 3 2 1
8. Aesthetics (Trees, light, cramping or 5 4 3 2 1
spaciousness of wards/ rooms, colour of wards, rooms)
9. Skill profile of doctors and other 5 4 3 2 1
healthcare professionals
10. Expenses (or costs) 5 4 3 2 1
Where do u find the cost high? If found high in which department or treatment?
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2. Information pertaining to patient’s rating of the staff
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3. Information pertaining to patient’s rating of the services provided
1. Diagnosis by Doctor 5 4 3 2 1
2. Compassion and reassurance by doctor 5 4 3 2 1
3. Patience or attention by Doctor 5 4 3 2 1
4. Personal attention 5 4 3 2 1
5. Consultation with Doctor of choice 5 4 3 2 1
6. Privacy of Consultation 5 4 3 2 1
7. Duration for receiving test results 5 4 3 2 1
8. Kitchen food (inpatients only)
a) Timeliness 5 4 3 2 1
b) Cleanliness 5 4 3 2 1
c) As per Dietician instruction 5 4 3 2 1
9. No. of visits by Doctors (inpatient) 5 4 3 2 1
10. Regularity of ward staff 5 4 3 2 1
11. Availability of Medicine 5 4 3 2 1
12. Information dissemination to relatives 5 4 3 2 1
13. Efficacy of treatment 5 4 3 2 1
14. Facilities for persons accompanying patient 5 4 3 2 1
15. Procedure at the time of discharge 5 4 3 2 1
16. Emergency services (ambulance etc.) 5 4 3 2 1
at trauma center
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__________________________________________________________________________________
__________________________________________________________________________________
_________________________________
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5. Information pertaining to Krupa details
1. Initial information 5 4 3 2 1
2. Discount on medicine 5 4 3 2 1
3. Range of diseases or ailments covered 5 4 3 2 1
4. Price 5 4 3 2 1
5. Range of options 5 4 3 2 1
6. Media approach 5 4 3 2 1
7. Post registration tracking 5 4 3 2 1
8. Documentation 5 4 3 2 1
9. Treatment offered at hospital 5 4 3 2 1
10. Information provided in booklet 5 4 3 2 1
11. Clarification of doubts 5 4 3 2 1
12. Association with other hospitals 5 4 3 2 1
13. Other benefits (such as income tax exemption) 5 4 3 2 1
14. Hospitality shown by Krupa staff 5 4 3 2 1
Q. Would you like to suggest your friends/ relatives/ neighbours to become a member of Krupa? If
yes, why? If no, why?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________
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