1. Century Hospital
The purposeof this form is to improve the OP pharmacy process to serve you
better. Therefore, I request you to collaborate with me by filling the
questionnaire given below using the following attributes:
1. Name : _______________________
2. Age (In Years) : ________________________
3. Gender : Male Female
4. Nationality : Indian Others (Specify)
__________________
5. Educational Qualification:
 Below matriculation
 Matriculation
 Higher Secondary
 Degree and above
6. Marital Status : Married Single
7. Sourceof information about Century Hospital:
 Advertisement
 Friends & Relatives
 Doctors Reference
 Others
Specify......................................................
8. Is this your first visit to Century Hospital: Yes No