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Questionnaire template

Patient Care Experience (Customer feedback)

Measures patients' views of their overall care, clinician communication, service quality and importance, and perceived health change.

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Customer · Customer feedback. All Customer templates

Questions in this template

Your Overall Experience

  1. We would like to hear how your recent care went. Please answer honestly; your views help us raise the standard of the services we provide.

  2. How would you rate your experience of our care overall?

    Choose one:

    • 1 - Very poor
    • 2 - Poor
    • 3 - Average
    • 4 - Good
    • 5 - Very good

  3. Which of the following services have you used? Select all that apply.

    Choose any that apply:

    • Emergency care
    • Outpatient appointments
    • Hospital stay
    • Diagnostic tests
    • Vaccinations
    • Preventive check-ups

Your Clinician

  1. Thinking about the clinician who treated you, how much do you agree with each statement?

    • They took my concerns seriously and heard me out
    • They explained my condition and the treatment choices in a way I understood
    • They showed care and understanding for my situation
    • They involved me in decisions about my treatment

    For each row: choose one:

    • Strongly disagree
    • Disagree
    • Neither agree nor disagree
    • Agree
    • Strongly agree

Quality of Our Services

  1. How would you rate each of the following?

    • How quickly you could get an appointment
    • How long you waited on the day of your visit
    • Cleanliness of the building and rooms
    • Condition of the medical equipment
    • Information given to you by the care team

    For each row: choose one:

    • Very poor
    • Poor
    • Average
    • Good
    • Very good

  2. How important is each of the following to you when you receive care?

    • How quickly you could get an appointment
    • How long you waited on the day of your visit
    • Cleanliness of the building and rooms
    • Condition of the medical equipment
    • Information given to you by the care team

    For each row: choose one:

    • Not at all important
    • Slightly important
    • Moderately important
    • Very important
    • Extremely important

Effect on Your Health

  1. Since receiving our care, how has your health changed?

    Choose one:

    • Much worse
    • Slightly worse
    • No change
    • Slightly better
    • Much better

  2. If you wish, tell us more about how your health has changed.

    Condition: Shown once the previous question is answered

    Open answer