Questionnaire for the

Insured/Patient

(PLEASE ANSWER EACH QUESTION SPECIFICALLY WITHOUT USING “--“OR NOT

APPLICABLE)

 Kindly specify the complaints with which you were admitted.

 Which doctor did you consult first time for the present complaints?

 What was the Date & Time of Admission & Discharge in the Hospital?

 How many times the treating doctor used to visit you during
Hospitalization? What is the name of the doctor?

 For how many days you were suffering from the symptoms &
signs after hospitalization? Specify Each?

 Any money has been taken by hospital during hospitalization / after

PMJAYcard shown?

 Satisfied with treatment: Yes/ No… If NO, please specify

During hospitalization period you was stay at hospital or In your Home:

Hospital

 Please share referrer name of this hospital :

 Distance from your home to the Hospital :

The answers given by me for the above questions are true to the best of my
knowledge. Name of Beneficiary:

PMJAY Card No. :

AADHAR /VOTER Card No:

PMJAY CASE No:

Date:

Sign:

Name and Sign of Investigator: