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Patient Questionnaire

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

How satisfied are you with the service?

Please rate your satisfaction on a scale from 1 (very dissatisfied) to 5 (very satisfied).
2

What is the main reason for your visit?

Please select the most relevant option.
3

How would you rate the cleanliness of the facility?

Please rate the cleanliness on a scale from 1 to 10 (1 being very dirty and 10 being very clean).
4

Are you satisfied with the waiting time?

Please select yes or no.
5

Please share any additional comments or feedback.

Feel free to write any comments or suggestions.
6

Would you recommend our services to others?

Please select yes or no.
7

How would you rate the professionalism of the staff?

Please rate the professionalism on a scale from 1 to 10 (1 being very unprofessional and 10 being very professional).
8

Did the doctor address all your concerns?

Please select yes or no.
9

How easy was it to schedule an appointment?

Please rate the ease of scheduling on a scale from 1 to 5 (1 being very difficult and 5 being very easy).
10

What is your age group?

Please select the most appropriate age group.
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