Please Share your
Valuable Feedback
Patient Feedback Form
OT Feedback Form
Guest House Feedback
Patient Feedback Form
Patient Name
Age / Gender:
Country
City
Mobile Number
Treatment Start Date
Department / Therapy Taken
Major Health Concern / Problem
Reception & Appointments
Ease of Booking Appointments
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Billing & Registration Process
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Waiting time Management
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Reception Staff Politeness & Front desk Management
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Overall Coordination
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Overall Cleanliness & Hygiene at the Clinic
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Treatment (Doctors & Therapists)
Did Doctor Kaviarasu explain your condition clearly?
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Clarity of treatment plan given by Doctor Kaviarasu
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Junior Doctor’s treatment and care
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Therapist’s friendliness & approachability
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Therapist’s skill & knowledge
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Individual attention during therapy
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Punctuality of sessions
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Comfort during treatment procedures
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Communication & clarity of instructions
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Doctor-wise Rating
Doctor Name
Dr. Archanaa
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Dr. Jyothika
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Dr. Muppudathi
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Therapist-wise Rating
Therapist Name
Kavya
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Kaviselvi
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Periakka
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
6 — Not Attended
7 — Need to improve
Suggestions for Improving the Treatment and Therapy Process
Overall Experience
Level of improvement in your health condition since the start of treatment
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Are you attending treatment regularly?
1 – Regular
2 – Rarely miss a session
3 – Irregular
Overall rating of the clinic
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Would you recommend Akayukthi Nature Cure Centre and its Naturopathy treatment to others?
Yes
No
Maybe
Suggestions / Additional Feedback
Send
OT Feedback Form
Patient Name
Age / Gender:
Date of Visit:
Administration & Scheduling
Smoothness of appointment / booking process
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Clarity of information provided about session timings
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Waiting time before sessions
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Senior Therapist Feedback
Explanation of condition and treatment plan
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Understanding of your needs and challenges
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Professionalism and communication
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Clarity of instructions for home exercises
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Junior Therapist Feedback
Assistance provided during therapy sessions
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Professionalism, behaviour, and communication
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Care, patience, and attentiveness
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Facility & Environment
Comfort and organisation of the waiting area
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Overall ambience of the department
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Overall cleanliness of the department
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Was the space child friendly?
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Accessibility & Location
Ease of locating the Occupational Therapy Department
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Parking / transport access convenience
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Safety & Comfort
Feeling of safety throughout therapy
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Treatment Outcome
Improvement noticed since starting therapy
No improvement
Slight improvement
Moderate improvement
Significant improvement
Excellent improvement
Confidence in continuing home exercises
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Overall Experience
Overall satisfaction with the Occupational Therapy Department
1 – Very Poor
2 – Poor
3 – Average
4 – Good
5 – Excellent
Would you recommend this department to others?
Yes
No
Additional Comments / Suggestions
What did you like most about the therapy?
Send
Guest House Feedback
Akayukthi Nature Cure Centre –
Guest House Feedback Form
Guest Name
Age
Check-in Date
Check-out Date
Room No.
Contact No
How would you rate the cleanliness of your room and bathroom?
Poor
Good
Excellent
Was your room comfortable (bed, lighting, ventilation, temperature)?
Not comfortable
Moderate
Very comfortable
How would you rate the quality and taste of the food provided?
Poor
Good
Excellent
Were meals served on time and as per your diet/therapy requirements?
No
Sometimes
Always
Was the food served hot and fresh?
Yes
No
Sometimes
How would you rate the hospitality and friendliness of the guest house staff?
Poor
Good
Excellent
Did you feel safe and secure during your stay?
No
Somewhat
Completely
Was the guest house environment calm, peaceful, and supportive for healing?
Not at all
To some extent
Completely
How would you rate the availability and cleanliness of common areas (dining hall, lounge, etc.)?
Poor
Good
Excellent
Was the stay well-coordinated with your therapy schedule (timely communication and guidance)?
No
Partly
Yes, completely
How would you rate the transport facility between the clinic and the guest house?
Poor
Good
Excellent
Overall, how satisfied are you with your stay at the guest house?
Unsatisfied
Satisfied
Very Satisfied
Would you recommend our guest house to others?
No
Maybe
Definitely Yes
Appreciation (Optional)
Would you like to mention anyone specific who has done an excellent job? Please share their name and what you appreciated:
Areas for Improvement (Optional)
Would you like to mention anyone specific or any service that could be improved? Please explain:
Suggestions for Improvement
Send
×
Contact Us
×
