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Questionnaire template

Patient Experience Feedback (Patient 2)

Collects patients' ratings of care quality, communication, staff, waiting time, involvement and overall experience after a visit.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Overall Experience

  1. Thank you for sharing your experience with us. Your feedback helps us raise the quality of care we provide to every patient.

  2. How would you rate the quality of the care you received overall?

    Choose one:

    • Very poor
    • Poor
    • Fair
    • Good
    • Very good

  3. How satisfied are you with the way your care team kept you informed?

    Choose one:

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

  4. How likely would you be to recommend us to a friend or relative who needed similar care?

    Choose one from a list:

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

About Your Visit

  1. How would you rate the cleanliness of our premises?

    Choose one:

    • Very poor
    • Poor
    • Fair
    • Good
    • Very good

  2. How professional did you find our staff?

    A number from 1 to 10

  3. Was the time you waited reasonable?

    Choose one:

    • Yes
    • Not sure
    • No

  4. Did staff deal properly with the questions and concerns you raised?

    Choose one:

    • Yes
    • Partly
    • No

  5. What was left unresolved, or could have been handled better?

    Asked only when q_concerns_addressed.outcome is not None and q_concerns_addressed.outcome >= 2

    Open answer

Communication and Involvement

  1. How satisfied were you with how clearly your treatment was explained?

    Choose one:

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

  2. Is there anything about the explanations you were given that you would like to add?

    Open answer

  3. How would you rate the compassion and understanding your clinician showed you?

    Choose one:

    • Very poor
    • Poor
    • Fair
    • Good
    • Very good

  4. Were you involved as much as you wanted in decisions about your treatment?

    Choose one:

    • Yes, fully
    • Yes, to some extent
    • No

Final Thoughts

  1. What could we do to improve our services?

    Open answer

  2. Taking everything into account, what score from 1 (very poor) to 10 (excellent) would you give your experience?

    A number from 1 to 10