Department / Section Visited Choose... ADULT CHEMOTHERAPY ANIMAL BITE CENTER CATHETERIZATION LAB DENTAL DRUG TREATMENT REHAB CENTER EMPLOYEES HEALTH SERVICE FAMILY MEDICINE FAMILY PLANNING HEMODIALYSIS HOSPICE CARE - OPD INDUSTRIAL CLINIC MOLECULAR LABORATORY NUCLEAR MEDICINE NUTRITION WELLNESS - OPD OCCUPATIONAL THERAPY - OPD OPD PEDIATRIC CHEMOTHERAPY PERITONEAL DIALYSIS PHYSICAL THERAPY OPD PSYCHIATRY - OPD PULMONARY RADIOLOGY RADIOLOGY ONCO SPEECH THERAPY - OPD SWABBING AREA - HESU UNDER FIVE CLINIC (PEDIATRIC)

Date of Consultation / Visit / Discharge :

Have you visited this hospital/office before?

The Respondent of this Survey Form:

Religion:

Age (in numbers)

Sex Choose... Female Male No Answer

Educational Attainment:

1. The waiting areas we used were clean, orderly, and comfortable.
2. The toilets and bathrooms inside the facility were kept clean, orderly and with a steady water supply.

3. The patients’ rooms were kept clean, tidy, and comfortable.
4. The food serve was Nutritious and Palatable

5. Consultation process
6. Admission process
7. Laboratory process
8. Radiology processes (MRI, CT-Scan, X-ray, Ultrasound, Mammogram)
9. Pharmacy Process

10a. Discharge Process - Discharge process in the ward
10b. Discharge Process - Billing
10c. Discharge Process - Cashier
11. Request/Release of Documents from this Facility
12. Process of Request for Assistance from Medical Social Service

13. The medical condition and procedures were discussed clearly.
14. Our sentiments, cultural background, and beliefs were heard and considered in the treatment procedure.
15. We were given the chance to decide which treatment procedure shall be performed.

16. The discharge instructions were discussed to us clearly before we were allowed to go home, including the time/date and site of the follow-up consultation.
17. For those eligible for assistance from Malasakit Center: all my medical costs were covered for this particular medical treatment/ admission

1. Doctor 2. Nurse 3. Nursing Attendant / Midwife 4. Security 5. Radiology (MRI, CT-Scan, X-ray, Ultrasound) 6. Pharmacy 7. Laboratory 8. Admitting Staff