1. Health Care Satisfaction Survey  [Date] 1
Health-CareSatisfactionSurvey CareCircle
JayaNagar,
Bengaluru
CareCircle requests your help. Please complete the following Survey based on your current health. Your decisions
help us craft a better Health Care Product. Thank you for your time.
Your Name: Hospital Name: Phone Number:
Gender: Date:
What was the reason for you visit to the hospital today
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How often do you visit the Hospital for your Health care
 3 Times a week  Every two weeks  Monthly  Yearly
How do you think you have experienced your treatment this day ?
 Less than expected  As expected  More than expected  Consistently more
Kindly mention any discomfort you face during the course of your treatment ?
E.g. . Missing appointment, forget to take your tablets, etc…….
1)___________________________________________________
2)___________________________________________________
3)____________________________________________________

2. Health Care Satisfaction Survey  [Date] 2
How often do you forget to take your tablets, or failing to carry your Medical records to
the doctor
 Very Often  Occasionally  A Few times  Never
If you were given a chance to improve the present Health care system, What are the
initial things you would immediately change ?
1)_______________________________________________
2)_______________________________________________
3)_______________________________________________
What is your general type of enquiry for a Health care service incase if you get sick
 Search Online  Ask Your Friends,
Family
 Directly Visit your
nearest Hospital
 ________________
( If Others )
Would you be interested to try if there is a simple solution to help you with digitalize
health records?
 I Don’t care  May be I’ll try  I Like the idea  ________________
( If Others )
Kindly rate the following digitalization ideas on a scale of 1 (Bad Idea) to 5 (Best Idea)
1) Book Doctor Appointment from your phone without making a call
 1  2  3  4  5
2) Digitalize health records
 1  2  3  4  5
3) Help with taking Medications on time
 1  2  3  4  5

3. Health Care Satisfaction Survey  [Date] 3
4) Track my health (exercise & vitals)
 1  2  3  4  5
5) Online Consultation with Doctor
 1  2  3  4  5