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Patient Survey Template

Care from Nurses

Throughout this hospital stay, how often did nurses treat you with kindness and respect?

Never Sometimes Usually Always

Throughout this hospital stay, how often did you get help as soon as you needed it, after you pushed the call button?

Never Sometimes Usually Always

Throughout this hospital stay, how often did nurses listen attentively to you?

Never Sometimes Usually Always

Throughout this hospital stay, how often did nurses explain matters in a way you could understand?

Never Sometimes Usually Always

Care from Doctors

Throughout this hospital stay, how often did doctors treat you with kindness and respect?

Never Sometimes Usually Always

Throughout this hospital stay, how often did doctors explain matters in a way you could understand?

Never Sometimes Usually Always

Throughout this hospital stay, how often did doctors listen attentively to you?

Never Sometimes Usually Always

Hospital Environment

Throughout this hospital stay, how often were your room and bathroom held clean?

Never Sometimes Usually Always

Throughout this hospital stay, how often was the range around your room quiet at night?

Never Sometimes Usually Always

Hospital Experience

Throughout this hospital stay, did you require assistant from nurses or other hospital workers when getting to the bathroom or in using a bedpan?

Yes No

Throughout this hospital stay, did you feel any pain?

Yes No

Throughout this hospital stay, were you given any medicine that you never took before?

Yes No

Leaving the Hospital

Before leaving, do you plan to go straight to your own home, to someone else’s home, or to another health facility?

Own home Someone else’s home Another health facility

Overall Rating of the Hospital

On a scale from 0 to 10, (0-the worst hospital possible; 10-the best hospital possible) how would you rate this hospital during your stay?

Select 10 - Best hospital possible 9 8 7 6 5 4 3 2 1 0 - Worst hospital possible

Would you suggest this hospital to friends and family?

Definitely Yes Probably Yes Probably No Definitely No

About you

Throughout this hospital stay, were you admitted to here through the emergency room?

Yes No

In general, how would you rank your overall mental or emotional health?

Excellent Very good Good Fair Poor

How would you rate your overall health?

Excellent Very good Good Fair Poor

Any comments?

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Please note that this checklist template is a hypothetical example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.