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Questionnaire template

Patient Satisfaction Survey

Measures patients' satisfaction with care, facility, staff conduct, communication and treatment outcome.

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Customer · Customer review. All Customer templates

Questions in this template

Your Care Overall

  1. Thank you for helping us improve the care we provide. The survey takes about ten minutes and is about your recent care with us.

  2. Overall, how satisfied are you with the care you received from us?

    Choose one:

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

  3. How much do you agree with each of these statements?

    • I was seen promptly when I needed care
    • The facility was clean
    • The facility was comfortable
    • Staff treated me with courtesy and respect
    • I was kept up to date about my treatment

    For each row: choose one:

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

Our Staff

  1. Which of these staff groups did you deal with a lot? Select all that apply.

    Choose any that apply:

    • Doctors
    • Nurses
    • Reception
    • Billing
    • Facilities and maintenance

  2. Please tell us about any particularly good or poor experiences you had with these staff.

    Condition: Shown when at least one staff group was selected

    Open answer

Your Treatment

  1. How satisfied are you with the progress or result of your treatment so far?

    Choose one:

    • Very dissatisfied
    • Dissatisfied
    • Neither satisfied nor dissatisfied
    • Satisfied
    • Very satisfied
    • Too early to say

  2. Is there anything you would like to share about how your treatment was planned or carried out?

    Open answer

About You

  1. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  2. In what year were you born?

    A number from 1910 to 2026