Patient satisfaction questionnaire template

Dear Patient,

Thank you for visiting us. By filling out this quick 5-10 minute survey, you will help us to provide better care in future.

1. Gender?

  • Male
  • Female

2. Age?

  • Under 18
  • 18-30
  • 31-45
  • 46-60
  • 61+

3. Race / Ethnicity?

  • Asian
  • African American
  • American Indian/Alaska Native
  • Europid
  • Hispanic or Latino

4. How would you rate the speed of care given?

  • Excellent
  • Good
  • Fair
  • Poor

Time in waiting room

  • Excellent
  • Good
  • Fair
  • Poor

Time in exam room

  • Excellent
  • Good
  • Fair
  • Poor

Waiting for tests to be performed

  • Excellent
  • Good
  • Fair
  • Poor

Waiting for test results

  • Excellent
  • Good
  • Fair
  • Poor

5. How would you rate the ease of getting care?

  • Excellent
  • Good
  • Fair
  • Poor

Ability to get in to be seen make an appointment

  • Excellent
  • Good
  • Fair
  • Poor

Hours center (hospital) is open

  • Excellent
  • Good
  • Fair
  • Poor

Convenience of center's (hospital's) location

  • Excellent
  • Good
  • Fair
  • Poor

Prompt return of calls

  • Excellent
  • Good
  • Fair
  • Poor

6. Which physician were you seen by?

  • Dr. - Name 1
  • Dr. - Name 2
  • Dr. - Name 3

7. How would you rate your Physician, Nurse, Other medical staff

  • Excellent
  • Good
  • Fair
  • Poor

Listens to you and takes enough time with you

  • Excellent
  • Good
  • Fair
  • Poor

Explains what you want to know

  • Excellent
  • Good
  • Fair
  • Poor

Gives you good advice and treatment

  • Excellent
  • Good
  • Fair
  • Poor

Friendly and helpful to you

  • Excellent
  • Good
  • Fair
  • Poor

Answers your questions

  • Excellent
  • Good
  • Fair
  • Poor

8. How would you rate all other staff (support, tech, etc.) attitude?

  • Excellent
  • Good
  • Fair
  • Poor

Friendly and helpful to you

  • Excellent
  • Good
  • Fair
  • Poor

Answers your questions

  • Excellent
  • Good
  • Fair
  • Poor

9. How would you rate your feeling about the facilities?

  • Excellent
  • Good
  • Fair
  • Poor

Neat and clean

  • Excellent
  • Good
  • Fair
  • Poor

Ease of finding where to go

  • Excellent
  • Good
  • Fair
  • Poor

Comfort and Safety

  • Excellent
  • Good
  • Fair
  • Poor

Privacy

  • Excellent
  • Good
  • Fair
  • Poor

10. How would you rate the cost of our services?

  • Unaffordable
  • Expensive
  • Affordable
  • Cheap

11. How would you rate our billing?

  • Excellent
  • Good
  • Fair
  • Poor

Explanation of charges

  • Excellent
  • Good
  • Fair
  • Poor

Collection of payments

  • Excellent
  • Good
  • Fair
  • Poor

12. Would you recommend us to your friends or relatives?

  • Yes
  • No

13. What do you like / dislike about our center (hospital)?

500

14. What can we do better?

500

Use template — it’s free

Patient Satisfaction Survey

Popularity 988 ×

The patient satisfaction evaluation questionnaire template will give you ideas for improving the operation of your facility, but also shows the individual details.

Use template — it’s free

The survey sample is ideal for

  • managers of hospital departments,
  • senior management,
  • directors of private medical centers and clinics.

Whether it is hospital facilities, specialized departments, health centers or private clinics, you will use the questionnaire everywhere thanks to a wide range of pre-prepared and fully editable questions. Gain an overview of how the patient perceives the length of waiting time, staff attitude, the level of services provided or the quality of equipment. Analysis of this data will show you the extent to which the real situation meets the expectations of patients and indicates room for change.

The questionnaire template can be fully edited. Survio will process your answers into well-arranged tables and graphs.

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