Inpatient Feedback Survey
  • Name:
  • Date of Birth:
  • Gender:

  • Height:
  • Weight:
  • What is the reason for admission?
  • How long was your stay?
  • Was your issue resolved?
  • please specify:

  • How was the state of healthcare administered?
  • How thorough were the doctors during the checkup?
  • Were clear explanations provided before treatment?
  • please specify:
  • Do you have healthcare benefits?
  • please specify what type
  • Do you have insurance?
  • please specify what type
  • How satisfied are you with the overall experience?
  • Is there anything that can be improved?

That's all, folks!

* End page and disqualification logic can only be seen in the live survey