Questions to ask >>

General Details

What is the patient's

District Facility ID Facility Facility Type Date
name?

- - - - - Text
Dir upper 347013 BHU BHU w/O alamzeb
sudess
Mubarak zeb
M.naveed
w/O Taj Muhammad
w/o Muhammad gulab
zahur ahmad
anha
zenab
M/o zubir
zakria
farwen
Jamshed
Gul anbar
salmena
 Facility Accesibility

How much time does it

What is the patient's What was the patient's
What is the patient's age? take for you to reach the
gender illness?
facility?

Number Male / Female Text Number (Mins)

30 female uTI 40
15 Male ARI 40
15 Male ARI 40
53 Male GBA 40
40 Female uTI 120
35 female ARI 120
25 Male Boil 15
4 female ARI 10
15 female ARI 10
60 Female ARI 30
2 Male puo 15
25 female Tonsillitis 20
35 Male ARI 10
80 male soure throat 5
59 female Renol colic 10
 Service Delivery

Do you face any

How much Is there public transport How long did you
problem while coming
does it cost service available to take you Were you seen have to wait
to facility such as
you to reach to the door of the primary by a doctor? before the doctor
transportation,
the facility? healthcare facility? gave you time?
distance, etc.?

Number (PKR) Yes / No Yes / No Yes / No Number (Mins)

50 yes no yes 3
50 yes no yes 3
50 yes no yes 3
50 yes no yes 3
300 yes no yes 3
300 yes no yes 3
0 yes no yes 3
0 yes no yes 3
0 yes no yes 3
50 yes no yes 3
0 yes no yes 3
0 yes no yes 3
0 yes no yes 3
0 yes no yes 3
0 yes no yes 3
 Was there any other Did the doctor give you sufficient
Was the doctor's Did you have enough
patient / staff present in the time to understand your medical
attitude towards privacy when the doctor
room when the doctor was background i.e., vitals, blood
you satisfactory? was observing you?
examining you? pressure, medical history etc.?

Yes / No Yes / No Yes Yes / No

yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
yes yes yes yes
 Treatment Overall Experience

How many
How much How many Would you
medicines did you
time did the medicines recommend this
receive from the
doctor spend were you facility to somebody
medicine store at the
with you? prescribed? else?
facility?

Number (Mins) Number (Meds) Number (Meds) Yes / No

5 5 3 yes
5 5 5 yes
5 5 3 yes
5 3 3 yes
5 4 2 yes
5 4 3 yes
5 5 5 yes
5 3 1 yes
5 4 2 yes
5 5 4 yes
5 3 3 yes
5 4 4 yes
5 3 3 yes
5 3 3 yes
5 5 3 yes
 Was the doctor
When you have a health problem, do Is there a service
available to see you
you fi rst go to your regular primary available at the
the last time you Remarks
health care facility before going to facility for you to
visited a facility for
some other health facility? lodge complaints?
care?

Yes / No Yes / No Yes / No

yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
yes yes yes
 11
1 11/1/2023 Morning Yes Male
2 11/2/2023 Evening No Female
7 11/7/2023

3 11/3/2023 Night

4 11/4/2023

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