QUESTIONNAIRE
Saint Anthony College of Roxas city, Inc. (Hospital)”. Do not leave any item in the questionnaire
unanswered. Please answer the questions truthfully. Your answers in this questionnaire shall be
Direction: Please indicate your answer by checking the appropriate boxes below.
Age: Gender:
21 - 30 Female
31 – 40 Male
41 – 50
50 And above
Widowed
15-21 Days
3 Weeks Above
Ward Admitted
Private Rooms
Ward Unit
Direction: Please rate some things about care rendered during your hospital stay in terms of
whether they were Excellent, Very Good, Good, Fair or Poor. Please check only one rating for
each statement.
5 – Excellent
4 – Very Good
3 – Good
2 – Fair
1 – Poor