Hospital Performance Evaluation Form

Ask patients to score the care, cleanliness and staff conduct they experienced during a stay, then invite open comments on each theme. Quality managers turn those scores into a clear picture of where service is slipping and what to fix first.

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Overall Rating

★ 1 star ★ 2 stars ★ 3 stars ★ 4 stars ★ 5 stars

How would you rate the quality of care you received at the hospital?

Did the hospital staff communicate effectively and clearly?

Always Most of the time Sometimes Rarely Never

Please provide any additional comments or suggestions regarding the quality of care and communication.

How would you rate the cleanliness of the hospital?

How would you rate the professionalism of the hospital staff?

How likely are you to recommend this hospital to others?

Please provide any additional comments or suggestions regarding the cleanliness, professionalism, and recommendation of the hospital.

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