Survey Questionnaire Example

June 28, 2011

Survey questionnaires are used in everyday life for purposes of finding specific information from people concerning a product or a service. These questionnaires are important as they foster accountability and consistency in the society upon evaluation. The respondents give the information seeker an opportunity to know what works in the market and outlines ways of improvement and progress.
An Example of a Patient Survey Questionnaire
Full Name_______________________________________
Address_________________________________________
Gender
Male / Female
Age
Below 21
Between 21-35
Between 35-65
Over 65
Physical Address________________________________________
Postal Address____________________________________________
Type of Patient
Out patient
In patient
Do you have health insurance?
_____________________________________
How are the prices of our health care services?
Cheap
Affordable
Expensive
Very expensive
How often do you attend our Hospital?
Occasionally
Frequently
Often
Rarely
How would you rate the care and service given by the following departments?
Administration
Radiology
Nursing
Laboratory
Surgery
Hospitality
Doctors
Pharmacy
What improvements would you suggest for our Hospital?
___________________________________________________
How is our customer service and health care in general?
________ Excellent
________ Satisfactory
________ Needs improvement
Would you recommend our health care services to your friends and relatives? (Kindly respond with yes / no as appropriate)
______________________________________________
One of our goals is to be a community health care provider. Do you think our health care and facilities are accessible?
_____________________________________________
Kindly explain your answer
__________________________________________________
Our goal is to give quality health care at reasonable and affordable prices. Do you think we have achieved this?
_________________________________________________
What suggestions would you recommend?
_______________________________________________________

Download Survey Questionnaire Example in Word Format

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