Meal Service Satisfaction Survey
Page One
1.
Please enter your contact information (optional)
First Name
Last Name
2.
Please tell us your relationship to the patient
-- Please Select --
Patient
Family Member
Other/Unknown
3.
Date of Response
4.
Please mark any special diets you may be on:
Diabetic
Low Sodium
Renal
None
If other, please specify
5.
Do you have any special texture requirements?
Chopped
Puree
Liquid
None
If other, please specify
6.
Please give us your feedback on our meal service using the following rating system:
1 Star = DISAGREE, 3 Stars = NEUTRAL, 5 Stars = AGREE
Flavor of Food
Temperature of Food
Variety of Food
Portion Size
Food Preferences/Dislikes were honored
7.
How would you rank the different meals?
Favorite
Neutral
Least Favorite
Breakfast
Lunch
Dinner
8.
Have you ever asked for a substitute meal in place of a meal you didn't like?
Yes
No
Did Not Answer
9.
If the answer to the question above was YES, did you receive a substitute meal?
Yes
No
Did Not Answer
10.
Have you been able to request and receive in-between meal snacks?
Yes
No
Did Not Answer
11.
QOL: How do you feel about our dining room program? (Main Dining Room, Large Activity Room, Progressive Self-Feeding)
Better than Expected
As Expected
Less than Expected
N/A
12.
What did you like best about the meal service?
13.
What suggestions do you have to improve the meal service?
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