Press 'Use this template' button at the top-right corner to copy this template and you can edit and use it.
Hospital Satisfaction Survey (Inpatient Guardians)

What is the main reason for the patient's (and your) decision to have surgery or inpatient treatment at the ABC clinic?

Competence of the medical staff

Friendliness of the medical staff

Friendliness of the employees

Good facilities

Good location

Cost competitive

Recommendation of a friend or acquaintance

Fame or reputation of the hospital

What is your gender? (Not patient's)



What is your age group? (Not patient's)

Under 20

20 ~ 25

26 ~ 30

31 ~ 35

36 ~ 40

41 ~ 45

46 ~ 50

51 ~ 55

56 ~ 60

61 ~ 65

66 ~ 70

Over 70

What is the patient's current status?

Hospitalized to prepare for surgery

Recovering from a surgery

Hospitalized for non-surgical treatment

Were you satisfied with our hospital to recommend us to your friends or colleagues?

Do you wish the patient to continue using our hospital?



Please select all area where our hospital needs improvement

Unfriendly employees

Unfriendly doctors

Less skilled doctors

Lacking or old facilities

Dirty hospital

Inconvenient parking

Difficult to find

Long wait time


Short counseling and consultation time

Complicated reservation, reception, payment process

Bad food

No improvement necessary

Lack of facilities for patient guardians

Please select all area where our hospital is exceptional

Friendly employees

Friendly doctors

Skilled doctors

Good facilities

Clean hospital

Convenient parking

Easy to find

Short wait time


Sufficient counseling and consultation time

Convenient reservation, reception, payment process

Good food

Good facilities for patient guardians

No exceptional areas

Lastly, please feel free to leave any comments, suggestions, commendations, or complaints you may wish to express to our hospital