Untitled Document

I came as a (Please Tick)

Patient

Relative

Visitor

Name:

Reg. No.:

Age:

Sex:

M

F

Address:

Phone

Email:

Bed:

Ward:

Doctor:

Diagnosis:

Treatment:

My hospital stay at CCWH & RI was because of the following factors:		Pleasant		Satisfactory		Unpleasant
The Hospital environment is		Good		Average		Poor
The Toilet(s) are		Good		Average		Poor
The Food / Diet is		Good		Average		Poor
The service of attending Doctors is		Good		Average		Poor
The service of attendant Nurses is		Good		Average		Poor
The Hospital Billing is		Good		Average		Poor
The Reception / Enquiry service is		Good		Average		Poor
The Admission Process is		Good		Average		Poor
The Discharge Process is		Good		Average		Poor
Overall I rate CCWH & RI as		Good		Average		Poor

Special Comments: