Hospital Cleanliness Feedback Form

Hospital Cleanliness Feedback Form
*Hospital Visit Type	Patient	Relative	Visitor
Personal Details
*Name		* CR No./Adm No
*Age DOB		*Gender
* Country		*State State
H.No.		Street
Location		*District
*City/Village		Pin Code
*Mobile No		Email ID
Cleanliness Rating

*Wards	Excellent	V.Good	Good	Satisfactory	Poor
*Doctor Consultation Room	Excellent	V.Good	Good	Satisfactory	Poor
*Toilets	Excellent	V.Good	Good	Satisfactory	Poor
*Wheel Chairs/Trolleys	Excellent	V.Good	Good	Satisfactory	Poor
*Stairs/ramps	Excellent	V.Good	Good	Satisfactory	Poor
*Canteens	Excellent	V.Good	Good	Satisfactory	Poor
*Roads/pathways	Excellent	V.Good	Good	Satisfactory	Poor
*Parking Area	Excellent	V.Good	Good	Satisfactory	Poor

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