Provincial Health Office

Martin Marasigan Memorial Hospital

Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-001

Simple Medical Consultations

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FEEDBACK FORM m- 15-001

Simple Medical Consultations

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

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1- Poor

1- Poor

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-002

FEEDBACK FORM m- 15-002

Long Medical Consultations and Treatment

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Long Medical Consultations and Treatment

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5- Outstanding

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3- Satisfactory

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HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-003

FEEDBACK FORM m-15-003
Provision of Medical Treatment for Emergency Cases

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3- Satisfactory

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2- Unsatisfactory

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HAPPY TO SERVE

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HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-004

FEEDBACK FORM m-15-004

Daily Assessment of Admitted Patients

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Daily Assessment of Admitted Patients

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5- Outstanding

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3- Satisfactory

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-005

FEEDBACK FORM m-15-005

Minor General Surgery

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Minor General Surgery

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3- Satisfactory

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-006

FEEDBACK FORM m-15-006

Obstetrics Deliveries
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3- Satisfactory

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-007

FEEDBACK FORM m-15-007

Gynecological Cases
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Gynecological Cases
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5- Outstanding

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3- Satisfactory

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2- Unsatisfactory

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-008

FEEDBACK FORM m-15-008

Major Surgery

Major Surgery
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5- Outstanding

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4- Very Satisfactory

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3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-009

FEEDBACK FORM m-15-009

Anesthetic Induction
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Anesthetic Induction
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5- Outstanding

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4- Very Satisfactory

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3- Satisfactory

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2- Unsatisfactory

2- Unsatisfactory

1- Poor

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-010

FEEDBACK FORM m-15-010

Tooth Extraction

Tooth Extraction
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5- Outstanding

5- Outstanding

4- Very Satisfactory

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3- Satisfactory

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2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-011

FEEDBACK FORM m-15-011

Treatment of Peridontal Disease

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Treatment of Peridontal Disease

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

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HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM m-15-012

FEEDBACK FORM m-15-012

Referral of Ward Patients

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Referral of Ward Patients

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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Signature of Patient

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Signature of Patient

HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-001

FEEDBACK FORM n-15-001

Provision of Bedside Health Education

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Provision of Bedside Health Education

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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_________________________
Signature of Patient

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_________________________
Signature of Patient

HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-002

FEEDBACK FORM n-15-002

Provision of Medications
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Provision of Medications
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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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_________________________
Signature of Patient

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_________________________
Signature of Patient

HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-003

FEEDBACK FORM n-15-003

In-Patient's Medical Complaint Resolved

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In-Patient's Medical Complaint Resolved

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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Signature of Patient

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_________________________
Signature of Patient

HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-004

FEEDBACK FORM n-15-004

Securing Consent for Significant Medical Procedure

Securing Consent for Significant Medical Procedure

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5- Outstanding

5- Outstanding

4- Very Satisfactory

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3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

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_________________________
Signature of Patient

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______________________________________________
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_________________________
Signature of Patient

HAPPY TO SERVE
HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-005

FEEDBACK FORM n-15-005

Provision of Health Education or Counseling

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Provision of Health Education or Counseling

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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______________________________________________
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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-006

FEEDBACK FORM n-15-006

Assistance to ROD during Emergency Cases/Minor
Surgery/ Examination of OPD Patient

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Assistance to ROD during Emergency Cases/Minor

Surgery/ Examination of OPD Patient

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5- Outstanding

5- Outstanding
4- Very Satisfactory
3- Satisfactory

4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor
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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-007

FEEDBACK FORM n-15-007

Assistance to Major Operation

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Assistance to Major Operation

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-008

FEEDBACK FORM n-15-008

Provision of Assistance to Patient or Patient's
Relatives

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Provision of Assistance to Patient or Patient's

Relatives

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

FEEDBACK FORM n-15-009

FEEDBACK FORM n-15-009

Assistance to OB Patients
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Assistance to OB Patients
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5- Outstanding

5- Outstanding
4- Very Satisfactory

4- Very Satisfactory
3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor
Comments/ Suggestions/ Recommendations:
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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-010
Assistance while transferring patient to other
hospital

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Thank you.

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-010
Assistance while transferring patient to other
hospital

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Thank you.
5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor
Comments/ Suggestions/ Recommendations:
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______________________________________________
______________________________________________
______________________________________________
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Signature of Patient

HAPPY TO SERVE

Comments/ Suggestions/ Recommendations:

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______________________________________________
______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-011

FEEDBACK FORM n-15-011

Assistance to Minor Operation

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Assistance to Minor Operation

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

______________________________________________
______________________________________________
______________________________________________
______________________________________________
_________________________
Signature of Patient

Comments/ Suggestions/ Recommendations:

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______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM n-15-012

FEEDBACK FORM n-15-012

TOWS, Meetings, Assemblies Conducted/

Facilitated

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TOWS, Meetings, Assemblies Conducted/

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5- Outstanding

5- Outstanding

4- Very Satisfactory

4- Very Satisfactory

3- Satisfactory

3- Satisfactory

2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor

Comments/ Suggestions/ Recommendations:

______________________________________________
______________________________________________
______________________________________________
______________________________________________
_________________________
Signature of Client

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______________________________________________
______________________________________________
______________________________________________

_________________________
Signature of Client

HAPPY TO SERVE

HAPPY TO SERVE

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM A-15-001
Provision of Assistance to Patient or Patients
Relatives

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Thank you.

Provincial Health Office

Martin Marasigan Memorial Hospital
Malvar cor. Mabini sts, Cuenca, Batangas
FEEDBACK FORM A-15-001
Provision of Assistance to Patient or Patients
Relatives

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Please rate the quality of our service.
Thank you.
5- Outstanding

5- Outstanding
4- Very Satisfactory
3- Satisfactory

4- Very Satisfactory
3- Satisfactory
2- Unsatisfactory

2- Unsatisfactory

1- Poor

1- Poor
Comments/ Suggestions/ Recommendations:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
_________________________
Signature of Patient

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______________________________________________
______________________________________________

_________________________
Signature of Patient

HAPPY TO SERVE