Patient Feedback Survey 2026

Demographics

© Australian Commission on Safety and Quality in Health Care 2018. This publication is licensed for use and distribution under a Creative Commons Attribution-Noncommercial-Share Alike (BY-NC-SA) v4.0 licence. https://creativecommons.org/licenses/by-nc-sa/4.0/

The following questions were developed with patients by the Australian Commission on Safety and Quality in Health Care (the Commission), to assess the experiences of patients across Australia.
Minor local changes (demographics, patient information) have not been endorsed by the Commission.

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* 1. Patient's Name (Optional):

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* 2. Date of admission:

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* 3. Doctor's Name (Optional):

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* 4. Postcode:

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* 5. Age of Patient:

0 - 17 years

18 - 34 years

35 - 49 years

50 - 64 years

65 - 79 years

80+ years

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* 6. Who is completing this survey?

Patient

Parent of Patient

Family of Patient

Carer

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* 7. Department:

Canning Unit (Day Patient Unit)

Park Ward

Terrace Ward

Endoscopy

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* 8. How many days were spent in hospital?

Day Patient

2 - 3

4 - 7

8 - 14

Over 14