🏥 St. Raphael Medical Center, Inc.

Mabalacat City, Pampanga  |  CONFIDENTIAL

📋 Family Planning Survey

← Back to Survey Selection
Instructions / Panuto: Kindly place a check (✓) on your choice based on your experience.
Pakilagyan po ng tsek (✓) ang inyong piniling kasagutan ayon sa inyong karanasan sa SRMCI.
Rating Scale:   5 – Excellent (Napakahusay)   4 – Very Good (Mas Mainam)   3 – Good (Mainam)   2 – Fair (Pangkaraniwan)   1 – Poor (Kailangan Pagbutihin)
I. Introduction to SRMCI
Is this your first confinement at SRMCI? *
Ito po ba ang una ninyong pagtigil bilang pasyente ditto sa SRMCI?
You selected SRMCI because it was: *
Pinili nyo po ang SRMCI dahil sa:
II. Attending Physician
Name of attending physician (DR./DRA.): *
Pangalan ng inyong manggagamot:
III-A. Health Care Provider Rating
Respecting me as a person. *
May paggalang sa akin bilang tao.
Showing care and compassion. *
Pagpapakita ng pagmamalasakit at pakikiramay.
Letting me say what mattered to me about my birth control method. *
Pagpapaalam na mahalaga sa akin ang tungkol sa aking birth control.
Giving me an opportunity to ask questions. *
Pagbibigay sa akin ng pagkakataong magtanong.
Taking my preferences about my birth control seriously. *
Sineseryoso ang aking mga kagustuhan tungkol sa aking birth control.
Considering my personal situation when advising me about birth control. *
Isinasaalang-alang ang aking personal na sitwasyon kapag pinapayuhan ako tungkol sa birth control.
Working out a plan for my birth control with me. *
Paggawa ng isang plano para sa aking birth control sa akin.
Giving me enough information to make the best decision about my birth control method. *
Pagbibigay sa akin ng sapat na impormasyon upang makagawa ng pinakamahusay na desisyon.
Telling me how to take or use my birth control method most effectively. *
Sinasabi sa akin kung paano gamitin ang aking birth control method sa mahusay na pamamaraan.
Telling me the risks and benefits of the birth control method I chose. *
Sinasabi sa akin ang mga panganib at benepisyo ng birth control method na aking pinili.
Answering all my questions. *
Sumasagot sa lahat ng mga tanong ko.
III-B. Family Planning Checklist
Waiting room has a poster on family planning. *
Follow-up card filled with date of appointment was given. *
Provider explained how the method works. *
Demonstrated how to use the method. *
Described possible effects. *
Described the possibility of changing method if not happy. *
Described follow-up visit. *
III-C. Qualitative Data
What did you like about your interaction with your family planning provider today? Why? *
What did you dislike about your interaction with your family planning provider today? Why? *
What did you like about your experience seeking FP services at this hospital? Why? *
What did you dislike about your experience seeking FP services at this hospital? Why? *
III-D. Comments and Suggestions
Comments and Suggestions: *
III-E. Staff Commendation
Name(s) of hospital staff you wish to commend for high quality services: *
📋 Patient / Informant Information (Mga Pagkakakilanlan)