Foreigner’s Questionnaire
Dear patient:
Hi, this is a satisfaction examination. We hope we can understand the medical quality degree of satisfaction of the patient through this survey. In order to protect your right, this satisfaction examination will keep in secret. Thanks for your cooperation.
Songshan Armed ForcesGeneralHospital
Sincerely
One:Diagnosis background (make a “” in □)
1. □First diagnosis 2. □Subsequentdiagnosis 3. □ Patient accompanying
2. Please choose the first three primary reasons that make you come here for diagnosis.
( 1 ) □ Quite near home
( 2 ) □ The transportation is convenient
( 3 ) □ Recommendation of friends and relatives
( 4 ) □ Familiar with hospital environment
( 5 ) □ The medical service is well-equipped
( 6 ) □ The hospital takes to complain and deal it properly
( 7 ) □ Good medical skill
( 8 ) □ Medicalenvironment is sanitary
( 9 ) □ Appointment、diagnosis and getting the medicine is fast
( 10 ) □ The clinics of OPD is complete
( 11 ) □ Recovery after diagnosis
( 12 ) □ Others ______
3. How do you register for diagnosis today?
( 1 ) □Walk-in Appointments
( 2 ) □ Telephone appointment
( 3 ) □ Internet appointment
( 4 ) □Hospital Room Appointments
( 5 ) □Automaticappointment machine
( 6 ) □ Others ______
Two:Satisfaction examination of medical environment (make a “” in □)
- Convenience of transportation
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
Three:Satisfaction examination of appointmentand waiting time (make a “” in □)
- Service attitude of service counter
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
2. The efficiency of solving problems by registrationpersonnel
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
3. Waiting time of formality
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
4. Others ______
Four: Satisfaction examination of waiting time for diagnosis and OPD (make a “” in □)
- Time of waiting for medical advice
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
2. The environment and space of waiting room
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
3. The secret of consulting room
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
4. The attitude of doctor
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
5. The cost of time of diagnosis
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
6. The explanations of patients’condition by doctor
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
Five: The satisfaction of assay and injection,(make a “” in □)
- Do you go for a assay?
□ Yes
□ No (jump to question II)
- The process of assay:
1. Time of waiting for assaying and results
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
2. The attitude of medical personnel
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
3. The explanation of the results by medical personnel
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
4. The cleanness of medical instruments
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
II. The process of the injection:
- Do you have an injection?
□ Yes
□ No (jump to Question Six)
- Time of waiting for injection
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
3. The attitude of medical personnel
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
4. The medical skill of injection
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
Six: The satisfaction of time for getting medicine (make a “” in □)
- Waiting time for getting medicine
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
2. The explanation of taking medicine
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
3. Calling system of pharmacy
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
Seven: The satisfaction of time for diagnosis (make a “” in □)
- Which process takes the time most
□ Appointment
□ Waiting for medical advice
□ Diagnosis
□ Assay
□ Injection
□ Getting medicine
□ Other ______
2. How much time do you spent from arriving at the hospital to start to the conclusion to get the medicine
□ One hour
□ Tow Hours
□ Three hours
□ Half a day
□ Almost a day
3. The fluency of seeking medical advice
□ Very unsatisfied
□ Unsatisfied
□Ordinary
□ Satisfied
□ Very satisfied
Eight: Personal basic background
- Gender:
□ Male
□ Female
2. Age
□ Under 18
□ 19~45
□ 46~64
□ above 65
Please mail to when you finished. Thank you very much.