Retirement home resident questionnaire template

Hello,

Please take a few minutes of your time to fill in the following survey.

1. How long have you been a resident at the home?

  • Less than 1 year
  • More than 1 year
  • More than 3 years
  • More than 5 years
  • Longer than 10 years

2. Are you completely satisfied with the facilities, environment and equipment supplied to you at the home?

  • Very satisfied
  • Satisfied
  • Indifferent
  • Dissatisfied
  • Very dissatisfied

3. Please rate the following statements with regard to the staff and their service:

Please mark: 1 - Excellent, 5 - Worst

  • 1
  • 2
  • 3
  • 4
  • 5

The reception staff are always kind and helpful

  • 1
  • 2
  • 3
  • 4
  • 5

The nurses and carers are professional and attentive.

  • 1
  • 2
  • 3
  • 4
  • 5

The nurses and carers are friendly and sensitive to your needs

  • 1
  • 2
  • 3
  • 4
  • 5

The nurses and carers always do their best to meet my individual needs

  • 1
  • 2
  • 3
  • 4
  • 5

4. How would you rate the quality of your accommodation?

5. Are you happy with the quality of the food served at the home? Please mark the following statements according to your own personal feelings and experiences:

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

The food is always fresh and of a good quality

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

The food is tasty and nutritious

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

The food is well presented

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

There is always a diverse choice of dishes

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

I am extremely satisfied with the diet i am provided at the home

  • I strongly agree
  • I agree
  • I don't know
  • I disagree
  • I strongly disagree

6. How satisfied are you with the home's nursing and care services?

  • Very satisfied
  • Satisfied
  • Indifferent
  • Dissatisfied
  • Very dissatisfied

7. Would you say that the social and recreational activities at the home are beneficial and to your liking?

  • Yes

8. Do you feel dignified and respected at the home?

  • Yes

9. Is there anything you would like to see improved about the home?

500

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Retirement Home resident survey

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What comfort and facility level does your home for the elderly offer to its residents? Let them evaluate the service you provide in this questionnaire template.

Use template — it’s free

The survey sample is ideal for

  • owners and operators of homes for the elderly,
  • other care facilities.

Behavior of staff, equipment of rooms and general material equipment, variety of food, quality of nursing and care services or a range of leisure activities. Does everything work as it should? The home for the elderly evaluation questionnaire provides a set of pre-prepared questions focused on these and other aspects. Pay attention to what your clients lack and what they expect. Make their stay in your facility more pleasant and give them a feeling of dignified old age.

The questionnaire template can be fully edited. Survio will process your answers into well-arranged tables and graphs.

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