Questionnaire template
Patient Experience Feedback (Patient 1)
Collects patients' ratings of a recent hospital or clinic visit, covering staff, treatment explanations and follow-up care.
Preview
Healthcare · Patient. All Healthcare templates
Questions in this template
Overall Experience
Thank you for telling us about your recent visit. Your feedback helps us improve care for every patient.
-
Overall, how would you rate the care you received on your most recent visit?
Choose one:
- Poor
- Fair
- Good
- Very good
- Excellent
Your Care Team
-
How would you rate the skill and knowledge of each group of staff?
- Doctors
- Nurses
- Laboratory staff
For each row: choose one:
- Poor
- Fair
- Good
- Very good
- Excellent
- Did not see
-
How would you rate the courtesy and warmth of each group of staff?
- Doctors
- Nurses
- Laboratory staff
For each row: choose one:
- Poor
- Fair
- Good
- Very good
- Excellent
- Did not see
-
What one thing could our staff have done to make your visit better?
Open answer
Treatment and Follow-up
-
How satisfied are you with each of the following?
- How your treatment was explained to you
- Instructions for caring for yourself afterwards
- How quickly follow-up questions were answered
- Appointment reminders
For each row: choose one:
- Very dissatisfied
- Dissatisfied
- Neither satisfied nor dissatisfied
- Satisfied
- Very satisfied
- Not applicable
About You and Your Visit
-
What is your gender?
Choose one:
- Female
- Male
- Non-binary
- Prefer not to say
-
How old are you?
A number from 18 to 120
-
Which department did you visit?
Choose one from a list:
- Emergency
- General practice or outpatient clinic
- Surgery
- Maternity
- Paediatrics
- Radiology or imaging
- Laboratory
- Other
-
Which other department did you visit?
Condition: Shown when Other is selected
Open answer