Dear Sir/Madam,

Warm Welcome and Wish You A Quick Recovery

Aravind Eye Hospital is committed to giving high quality medical care and quality service. As part of our ongoing commitment to provide you with the best possible service, we would really appreciate it if you would take a few moments to complete this questionnaire. Your feedback on our services is of great Importance to us. Your opinion would be used to improve our services and competence to serve you better.

1. Choice of our Hospital (Please tick on relevant choices to you only)

   a) Referred by a doctor
   b) Recommended by friends / Family
   c) Quality of Services and Treatment
   d) Friendliness and efficiency of the staff
   e) Tariff Rate
   f) Previous Good Experience
   g) Near by Hospital

   
   
2. Admission & Discharge Counter and Procedures

   	Excellent	Good	Avge	Poor	V.Poor
   a) Ease of getting through our Admission Procedures
   b) Efficiency, friendliness and warmth of our staff
   c) Helpfulness of our staff in attending you
   d) Efficiency and speed in Billing
   e) How would you rate our guidance to the room?

   
   
3. Accommodation

   	Excellent	Good	Avge	Poor	V.Poor
   a) Quiet, Comfort and Ambience of the Room/Ward
   b) The way our staff greeted and served at stay
   c) Room Cleaning, and other services
   d) Cleanliness of the toilets
   e) Working Condition of Electricals, doors etc

   
   
4. Catering/Food services

   	Excellent	Good	Avge	Poor	V.Poor
   a) The quantity of food served
   b) The food Item served you
   c) The Hot food items served you

   
   
5. Nursing services

   	Excellent	Good	Avge	Poor	V.Poor
   a) Nurse's attention and helpfulness
   b) Promptness in responding to requests
   c) Politeness and Friendliness
   d) Presence of the Nurses at the Nursing Station

   
   
6. Counseling Services

   	Excellent	Good	Avge	Poor	V.Poor
   a) Politeness and Friendliness
   b) Efficiencyand the ability to clear doubts
   c) Helpfulness of our counselors
   d) Your Satisfaction to time spent by the Counselor

   
   
7. Other services

   	Excellent	Good	Avge	Poor	V.Poor
   a) Investigations performed
   b) Security personnel and their Services
   c) Pharmacy and Optical shop
   d) Cafeteria and Refreshments
   e) Service of Telephone operator and Phone

   
   
8. Finally, Through your Experience at Aravind

   	Excellent	Good	Avge	Poor	V.Poor
   a) Over all Experience
   b) Would you recommend Aravind for other Patients?	Yes		No
   	(If No please go to Suggestions)
   c) In which area you like us to Improve further?	....................................................................................................
   .....................................................................................................................................................

Patient Name .................................................   M. R. No ................. Sex : Male     Female     Room No ......................   Date ......................