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: