Patient satisfaction questionnaire template

Dear Sir or Madam,

By filling out this survey, you help us increase the quality of our healthcare.

We truly appreciate your insight and your time.

Important: This survey is completely anonymous.

1. What is your gender?

Select one answer

  • Male
  • Female
  • Prefer not to say

2. What is your age?

Select one answer

  • Under 15
  • 15 - 20
  • 21 - 30
  • 31 - 40
  • 41 - 50
  • 51 - 60
  • Over 60
  • Prefer not to say

3. For how long did you stay in [name of your medical facility]?

Select one answer

  • 1 day or less
  • 2 - 4 days
  • 5 - 7 days
  • More than 1 week

4. Which unit were you admitted to during your hospitalization?

Select one answer

  • [Unit 1]
  • [Unit 2]
  • [Unit 3]

5. What is your overall satisfaction with your hospitalization?

(1 star = minimum satisfaction / 5 stars = maximum satisfaction)

6. How would you rate the individual aspects of our facility?

Select one answer in each row

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Cleanliness

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Comfort

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Privacy

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Safety

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Room amenities

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Food services

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

7. How much do you agree with the following statements?

Select one answer in each row

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff is skilled and experienced.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff is kind and caring.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff always responds to my requests and concerns.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff clearly communicates information about the treatment.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff works as a team, demonstrating coordination and professionalism.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff respects patient privacy and confidentiality.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The medical staff creates a safe and trusting environment.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

8. How easy was it for you to find your way around the facility?

Select one answer

  • Choose...
    • Choose...
    • Very easy
    • Rather easy
    • Rather difficult
    • Very difficult

9. How likely are you to recommend [name of your medical facility] to your friends and relatives?

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

Not at all likely

Extremely likely

10. Do you have any other suggestions for improving our services?

500

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🤒 Patient satisfaction survey 🤕

Popularity 1078 ×

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

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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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