Please take a few moments to provide your valuable feedback regarding the medical device you have been using. Your input is crucial in helping us improve our products and ensure the best possible care for all patients.
Scan this QR code to use this paper checklist on your smartphone or tablet or
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Title Page
Personal Information:
Name
Age
Gender
Contact Information
Medical Device Information:
Device Name
Manufacturer
Date of Installation/ Commencement of Use
Survey Questions:
How easy was it to learn how to use the device?
Did you receive adequate training on how to use the device?
How comfortable is the device to wear or use?
Does the device fit well and stay in place during use?
How effective has the device been in managing your condition?
Have you experienced any improvements in your condition since using the device?
How durable do you find the device?
Have you experienced any issues or malfunctions with the device?
On a scale of 1 to 10, how satisfied are you with the device?
1 (Very Dissatisfied)
2
3
4
5 (Neutral)
6
7
8
9
10 (Very Satisfied)
Would you recommend this device to others in a similar situation?
Additional Comments
Please feel free to provide any additional comments, suggestions, or concerns regarding the device.
Thank you for taking the time to complete this survey. Your feedback is invaluable to us in improving our products and services. If you have any further questions or require assistance, please don't hesitate to contact us.
Hrushikesh Kadam
Patient Survey Form
Please take a few moments to provide your valuable feedback regarding the medical device you have been using. Your input is crucial in helping us improve our products and ensure the best possible care for all patients.
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
