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Questionnaire template

Patient Satisfaction

Measures patients' satisfaction with care quality, cleanliness, staff, waiting, communication and involvement after a visit.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Your Overall Experience

  1. Thank you for sharing your feedback. It helps us improve the quality of care and the experience of every patient at our facility.

  2. Overall, how would you rate the quality of the care you received?

    Choose one:

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

  3. How satisfied are you with how your clinicians kept you informed?

    Choose one:

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

  4. How likely are you to recommend our facility to friends or family?

    Choose one from a list:

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

About Your Visit

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

    Choose one:

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

  2. On a scale from 1 to 10, how professional was our staff?

    Choose one:

    • 1 - Not at all professional
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10 - Extremely professional

  3. Was the time you had to wait acceptable to you?

    Choose one:

    • Yes
    • Not sure
    • No

  4. Were your questions and concerns dealt with properly?

    Choose one:

    • Yes
    • Somewhat
    • No

  5. Which questions or concerns were not fully dealt with? (optional)

    Condition: Shown when concerns were only partly or not addressed

    Open answer

Communication and Involvement

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

    Choose one:

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

  2. What about the explanation was unclear? (optional)

    Condition: Shown when the respondent was dissatisfied with the explanation

    Open answer

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

    Choose one:

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

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

    Choose one:

    • Yes, definitely
    • Yes, to some extent
    • No

Final Thoughts

  1. Do you have any other comments or ideas that would help us improve? (optional)

    Open answer

  2. On a scale from 1 to 10, how would you rate your experience with us overall?

    Choose one:

    • 1 - Very poor
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10 - Very good