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Questionnaire template

Patient Care Experience (Patient 3)

Measures patients' views of care quality, staff communication, the facility and follow-up after a recent visit.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Your Latest Visit

  1. Thank you for sharing your experience with us. Your answers help us improve the care and services we offer to every patient.

  2. Thinking about your latest visit, how would you rate the quality of care you received?

    Choose one:

    • Excellent
    • Very good
    • Good
    • Fair
    • Poor

  3. How satisfied were you with how long you waited before a clinician saw you?

    Choose one:

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

  4. How easy to understand was the explanation of your health condition?

    Choose one:

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

Talking with Our Staff

  1. How would you rate the way the clinician who treated you communicated with you?

    Choose one:

    • Excellent
    • Good
    • Fair
    • Poor
    • Very poor

  2. How well did the clinician listen to what you were worried about?

    Choose one:

    • Very well
    • Well
    • Moderately well
    • Slightly
    • Not at all

  3. Did you take part in decisions about your care and treatment?

    Choose one:

    • Yes
    • Not sure
    • No

  4. Is there anything else you would like to tell us about how our staff communicated with you? (optional)

    Open answer

Our Facility

  1. How would you rate the cleanliness of the facility?

    Choose one from a list:

    • Excellent
    • Good
    • Fair
    • Poor
    • Very poor

  2. How satisfied were you with how easy it was to find your way around the building?

    Choose one:

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

  3. What made it difficult to find your way around? (optional)

    Condition: Shown when the respondent was dissatisfied with navigation

    Open answer

  4. How could we make the facility more comfortable or accessible? (optional)

    Open answer

After Your Visit

  1. After your visit, did you get enough support with any follow-up care you needed?

    Choose one:

    • Yes
    • Not sure
    • No

  2. How likely are you to recommend our services to friends or family?

    Choose one:

    • Very likely
    • Likely
    • Neither likely nor unlikely
    • Unlikely
    • Very unlikely

  3. Which additional services or changes would you most like us to introduce? (optional)

    Open answer

  4. Rank these parts of our service from 1 (most important to you) to 5 (least important). Use each rank once.

    • Quality of care
    • Communication with clinicians
    • Cleanliness
    • Waiting times
    • Follow-up support

    For each row: choose one from a list:

    • 1
    • 2
    • 3
    • 4
    • 5