Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Medical Clearance Process Experience Survey
Captures how patients experience the medical clearance process — for surgery, sports participation, return to work, or travel — from scheduling through receiving the final decision. An AI follow-up interview digs into the moments that created confusion or delay, giving clinics concrete detail behind satisfaction scores.
設問の例
テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。
全13問・約7分
Q02
選択式必須
What type of medical clearance did you most recently go through?
- Pre-surgical clearance
- Sports or athletic participation clearance
- Return-to-work clearance
- Travel or immigration clearance
- Clearance for a procedure or treatment
- Other
Q03
オピニオンスケール必須
Before your appointment, how clear were you on what documents, tests, or steps the clearance would require?
スケール: 1 – 7
最小:Not clear at all最大:Extremely clear
Q04
評価スケール必須
How easy was it to schedule your clearance appointment?
範囲: 1 – 5
最小:Very difficult最大:Very easy
Q05
マトリクス必須
Thinking about the clearance visit itself, how much do you agree with each statement?
4行 × 5列
- The provider explained my results in terms I understood
- Staff answered my questions thoroughly
- I was told a clear timeline for when I'd get the final decision
- I felt the clearance decision was based on a thorough evaluation
列: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
選択式必須
From your first appointment to receiving the final clearance decision, how long did the whole process take?
- Same day
- 2-3 days
- About a week
- 2-3 weeks
- Longer than 3 weeks
- Still waiting
Q07
選択式
Did any of the following slow down or complicate your clearance? Select all that apply.
- Scheduling delays
- Missing paperwork or records
- Needing additional tests
- Unclear instructions
- Insurance or billing issues
- Difficulty reaching the office for updates
- None of these
Q08
オピニオンスケール必須
How confident are you that the final clearance decision was the right one for your situation?
スケール: 1 – 10
最小:Not at all confident最大:Completely confident
Q09
AIインタビュー
Reconstruct the specific moment in this respondent's clearance journey that most shaped their confidence and timeline ratings — for example a delay, an unclear explanation, or an unexpected extra test. Ask what happened, how it was (or wasn't) resolved, and what the office could have done differently. If they reported low confidence in the decision, probe exactly what left them unsure; if they reported a smooth, fast process, ask what specifically made it work well so it can be repeated.
Q10
オピニオンスケール必須
How likely are you to recommend this clinic or provider to someone who needs a similar clearance?
スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q11
選択式
What is your age range?
- Under 18
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q12
選択式
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
メッセージ
That's everything — thank you for sharing your experience! Your responses will be used to identify where the clearance process needs to be faster and clearer for future patients.
含まれる機能
AIによる深掘り
自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。
注意確認設問
急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。
AIが作成する設問文
文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。
自動レポート
回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。
他ツールとの比較
ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。
このテンプレートを選ぶ理由
- Covers the full clearance journey — scheduling, the appointment itself, and time-to-decision — across all major clearance types (surgery, sports, return to work, travel), not just one use case
- Uses an AI follow-up interview to reconstruct the specific moment that created confusion or delay, turning a satisfaction score into a concrete, actionable story
- Combines quantitative measures (opinion scales, ratings, a matrix of agreement statements) with open-ended AI probing, so clinics get both benchmarkable metrics and qualitative detail
- Automated per-response quality scoring and auto-generated reports mean clinics don't have to manually read every transcript to find the friction points
Jotform
Medical Clearance Form TemplateThis is a static, fillable clearance form intended to document a patient's fitness-for-activity sign-off (e.g., for a physician to complete), not a survey measuring the patient's experience of the clearance process. It's a documentation tool rather than a fielding-ready experience/satisfaction survey.
優れている点
- Simple, familiar drag-and-drop form builder for quickly producing a clearance document
- Widely used template library across many healthcare form types
- Easy to distribute and collect signatures/uploads for clearance paperwork
物足りない点
- A static form with fixed fields — no adaptive follow-up questioning to explore why a delay or confusion happened
- No mechanism to probe the specific moment in a patient's journey that caused friction
- No automated quality scoring or synthesized reporting on patient experience themes
SurveySparrow
Free Printable Medical Clearance Form Template For SurgeryA printable clearance form scoped specifically to surgery, designed to document clearance decisions rather than survey patients about their experience going through the process. It's positioned as a free, printable asset, not an interactive experience-tracking survey.
優れている点
- Free and easy to access/print
- Purpose-built for the surgical clearance use case
- Simple format that's quick for staff to implement
物足りない点
- Limited to surgery — doesn't cover sports, return-to-work, or travel clearance journeys
- Static question set only; no adaptive AI interview to dig into specific delay or confusion moments
- No per-response quality scoring or automatic report generation on patient sentiment
QuestionPro
Medical Examination Services Survey TemplateA genuine patient-facing survey template around medical examination services, making it a closer comparison than the two form templates above, though it's framed broadly around exam services rather than the specific clearance-decision journey (scheduling through final decision). It appears to be a standard fixed-question survey rather than one built around any single clearance-type scenario.
優れている点
- Established survey platform with broad customization and distribution options
- Covers general medical examination service satisfaction, which overlaps with parts of the clearance experience
- Comes with reporting/analytics tooling typical of QuestionPro's platform
物足りない点
- No adaptive AI follow-up interview to reconstruct the specific moment that caused delay or confusion
- Not scoped to the clearance decision journey specifically (scheduling → appointment → final decision) across surgery/sports/work/travel contexts
- No transparent, per-response AI quality scoring of open-ended feedback
よくあるご質問
「Medical Clearance Process Experience Survey」テンプレートにはどのような設問が含まれていますか？
すぐに使える設問が13問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes to share your recent experience getting medical clearance. Your honest feedback helps us…」・「What type of medical clearance did you most recently go through?」・「Before your appointment, how clear were you on what documents, tests, or steps the clearance would require?」。すべての設問は上でプレビューでき、自由に編集できます。
このアンケートの回答にはどのくらい時間がかかりますか？
回答者は通常、13問を約7分で回答し終えます。
テンプレートは編集できますか？
はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。
このテンプレートは無料で使えますか？
はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。
公開の準備はできましたか？
このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。
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