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Questionnaire template

Healthcare Experience and Personal Health

Gathers patients' ratings of recent healthcare services plus self-rated health, physical activity and diet quality.

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Healthcare · Mental health. All Healthcare templates

Questions in this template

Your Recent Healthcare

  1. Thank you for taking a few minutes to tell us about your healthcare and your health. Your answers will help us improve our services.

  2. Thinking about the past 12 months, how satisfied are you with the healthcare you received?

    Choose one:

    • Very dissatisfied
    • Dissatisfied
    • Neither satisfied nor dissatisfied
    • Satisfied
    • Very satisfied

  3. How would you rate the time you spent waiting to be seen?

    Choose one:

    • Poor
    • Fair
    • Good
    • Very good
    • Excellent

  4. How often did the people treating you explain things in a way you could easily follow?

    Choose one:

    • Never
    • Sometimes
    • Usually
    • Always

  5. How would you rate the cleanliness of the places where you received care?

    Choose one:

    • Poor
    • Fair
    • Good
    • Very good
    • Excellent

Your Health and Lifestyle

  1. In general, how would you describe your health?

    Choose one from a list:

    • Excellent
    • Very good
    • Good
    • Fair
    • Poor

  2. In a typical week, on how many days do you do at least 30 minutes of moderate physical activity, such as brisk walking or cycling?

    A number from 0 to 7

  3. How would you rate how healthily you eat?

    Choose one:

    • Poor
    • Fair
    • Good
    • Very good
    • Excellent

Your Suggestions

  1. What could we change to make your healthcare experience better?

    Open answer

  2. Is there anything else you would like to tell us?

    Open answer