Melomed Hospitals

RECEPTION

Staff were courteous and helpful

Admission procedure was speedy and efficient

Clear financial information was given to you on admission

Reception area was clean and tidy

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Patient Care Evaluation Form

Hi There! Please dont let the size of our form fool you. We have tested filling out the form, and we assure you it will not take more than 3 minutes of your time. This is one of the best places for you to voice your feelings towards the service level you experienced at one of our hospitals. If the questionnaire does not help you, please fill out the "General Comments" Box at the very bottom of this page.

HOSPITAL
	Hospital
	What made you choose this hospital?

PERSONAL DETAILS
	Name of Patient (optional)
	Contact Number
	Email Address
	Date

NURSING SERVICES
		Very Poor	Poor	Fair	Good	Excellent
	Neat and courteous
	Behaved professionally
	Explained all nursing procedures performed
	Listened to you and made an effort to attend to your needs
	Handled visitors / relatives courteously

ACCOMODATION
		Very Poor	Poor	Fair	Good	Excellent
	Room was clean and tidy on inspection
	Ward faciities were explained to you. eg. Nurses call system, toilets etc.)
	Bed linen and towels were changed regularly
	Equipment in your room was funtional (e.g. T.V., Nurses call system)
	If Not, What did not work?
	Did you report it?	Yes No
	Was it attended to?	Yes No
	Bathroom was kept clean and tidy
	Housekeeping staff were friendly and helpful

GENERAL
		Very Poor	Poor	Fair	Good	Excellent
	The pharmacy service met with your expectation
	Would you recommend this hospital to your family and friends?	Yes No
	If not, please help us understand why....
	Did you report it?	Yes No
	General Comments

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