Questionnaire

How Are You Doing?

We are committed to providing you with the best dining experience possible, so we welcome your comments. Please fill out this questionnaire, in addition of your admission document, and place it on your meal tray. Thank you.

Is there a family member or caregiver involved in your meal decisions whom we should consult or coordinate with?

Yes | No

If yes, who would it be?

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Are there any food textures or consistencies that you have difficulty eating?

Yes | No

If yes, what would it be?

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Are there any specific foods or beverages that you would like us to include or avoid during your stay?

Yes | No

If yes, what would it be?

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Would you like assistance from a nutritionist to plan your meals based on your specific dietary needs?

Yes | No

Do you have any other special requests or considerations related to your meals during your hospital stay?

Yes | No

If yes, what would it be?

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During your visit, will you have any family member you would like us to cater for?

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During your visit, will you have any event or special occasion you would like to celebrate? How might we make it more memorable?

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Please share any additional comments or suggestions.

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Patient’s details

[name]

[room number]

[admission date]

[staff name]

How Are We Doing?

We are committed to providing you with the best dining experience possible, so we welcome your comments. Please fill out this questionnaire and place it on your meal tray. Thank you.

The overall Food Service experience was:

1 2 3 4 5

Disappointing Exceptional

Please rate the quality of the service you received from your Food Service Assistant.

1 2 3 4 5

Disappointing Exceptional

Were you satisfied of our Food Service Assistant?

Yes | No

The meal selection was:

1 2 3 4 5

Disappointing Exceptional

The temperature of your meals and drinks was:

1 2 3 4 5

Disappointing Exceptional

Our serving size was:

1 2 3 4 5

Disappointing Exceptional

The meals taste was:

1 2 3 4 5

Disappointing Exceptional

Have you been happy with the diet offered to you?

Yes | No

Why/why not?

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If this wasn’t your first visit, have you noticed any change that we should be made aware of?

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Please share any additional comments or suggestions.

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Patient’s details

[name]

[last room number]

[discharge/completion date]

[staff name]