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Questionnaire template

Patient Care Experience (Feedback forms)

Measures patients' views of booking, quality of medical care, staff respect, cleanliness and privacy at a healthcare facility.

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Other · Feedback forms. All Other templates

Questions in this template

First Impressions

  1. We would value a few minutes of your time to hear about your recent experience with our healthcare services. Your feedback helps us improve the care we provide.

  2. Overall, what was your first impression of our services?

    Choose one:

    • Very positive
    • Somewhat positive
    • Neutral
    • Somewhat negative
    • Very negative

  3. How easy or difficult was it to book an appointment with us?

    Choose one:

    • Very easy
    • Somewhat easy
    • Neither easy nor difficult
    • Somewhat difficult
    • Very difficult

Your Medical Care

  1. How would you rate each of the following?

    • The quality of the medical attention you received
    • How promptly you were seen and treated
    • How clearly your condition and treatment were explained
    • How your concerns and questions were dealt with

    For each row: choose one:

    • Poor
    • Fair
    • Good
    • Very good
    • Excellent

Staff and Surroundings

  1. Thinking about your visit, was each of the following true?

    • Staff treated me with respect.
    • The facility was clean.
    • My medical information was kept private.

    For each row: choose one:

    • Yes
    • Not sure
    • No

Your Suggestions

  1. What could we do to improve our healthcare services?

    Open answer

About You (Optional)

  1. How old is the patient?

    A number from 0 to 120