Fields marked with * are mandatory.

Contact Information

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Name of patient: Mr Miss Mrs Mdm

IC No: - -

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If you are not a patient of the hospital, please provide us with
your details.
Name: Mr Miss Mrs Mdm

IC No: - -

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Address:
Apt Blk / House No.       Unit No.
                  -
Street Name:

Postal code:
Tel No:
E-mail:

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Which ward were you admitted to? *    MICUSICUWard 14Ward 15Ward 16Ward 17Ward 18Ward 25Ward 26Ward 27Ward 28Ward 29Ward 35Ward 36Ward 37Ward 38Ward 39Ward 44Ward 45Ward 46Ward 47Ward 48Ward 49Ward 59

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Admission

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Where were you registered for admission?
A & E
Ward
Patient Services Centre
Specialist Clinics

Please rate your level of satisfaction by ticking
the appropriate box:

Counter Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Courtesy
Competence

Ward

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Nursing Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Care & Concern
Knowledge & Skills

Medical Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Care & concern
Clarity of Explaination
Knowledge & Skills

Other Services

		Excellent	Good	Satisfactory	Poor	Very Poor	N.A.
Rehabilitation
Medical Social Services
X-ray Services
Quality Of Food
Hospital Facilities & Equipment
Cleanliness of the Hospital Facilities

		Excellent	Good	Satisfactory	Poor	Very Poor
Smooth co-ordination of care *

		Excellent	Good	Satisfactory	Poor	Very Poor
Discharge Procedure

		Excellent	Good	Satisfactory	Poor	Very Poor
What is your overall satisfaction with CGH? *

Do you wish to compliment any staff for outstanding care and services?


Please share your experience at the hospital with us and any suggestions on how we can further improve our services.