Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Patient Visit Experience & Care Feedback Survey
Captures how patients experienced a recent visit — wait times, communication, staff respect, and overall likelihood to recommend — with a best-worst prioritization of improvement areas and an AI follow-up that digs into the specific moment behind their recommendation score. Built for clinics, hospitals, and practice managers tracking care quality.
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12問・約7分
Q02
オピニオンスケール必須
How likely are you to recommend this clinic to family or friends?
スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q03
マトリクス必須
Thinking about your most recent visit, how would you rate each of the following?
5行 × 5列
- Time spent waiting
- Clarity of explanations from your care team
- Friendliness and respect from staff
- Cleanliness of the facility
- Ease of scheduling your visit
列: Poor · Fair · Good · Very good · Excellent
Q04
選択式必須
At your last visit, how long did you wait past your scheduled appointment time before being seen?
- Seen early or on time
- 1-15 minutes
- 16-30 minutes
- 31-60 minutes
- More than an hour
Q05
選択式必須
Did you feel you had enough time to ask questions during your visit?
- Yes, completely
- Somewhat
- Not really
- No, not at all
Q06
AIインタビュー
Reconstruct the specific moment that shaped the respondent's recommendation score: what happened, who was involved, and whether it was about wait time, communication, or something else. Anchor on whichever matrix item they rated lowest and ask them to walk through what occurred step by step. If the score was high, probe what specifically stood out so it can be reinforced elsewhere in the practice.
Q07
選択式
Which best describes the main reason for your visit?
- Routine checkup or physical
- New symptom or concern
- Follow-up on an existing condition
- Procedure or surgery
- Test results or lab review
Q08
ベスト・ワースト選択（MaxDiff）必須
If our clinic could only improve two of these, which would matter most and least to your experience?
- Shorter wait times
- More time with your provider
- Clearer explanation of diagnosis or treatment
- Better communication between visits
- Friendlier front-desk staff
- Easier online scheduling
- More comfortable waiting area
- Faster follow-up after the visit
各セットで最も良いもの・最も悪いものを選択最も良い:Most important to improve最も悪い:Least important to improve
Q09
自由回答（長文）
Is there anything else about your visit — good or bad — you'd like us to know?
Q10
選択式
What is your age range?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75+
- Prefer not to say
Q11
選択式
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer not to say
Q12
メッセージ
Thank you for sharing your feedback! Your responses go directly to our care quality team and help us fix real issues in scheduling, communication, and care delivery.
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
- Goes beyond satisfaction ratings with an AI follow-up interview that reconstructs the specific moment behind each patient's recommendation score, surfacing root causes static forms miss
- Uses a best-worst (max-diff) prioritization exercise so clinics know exactly which improvement areas matter most versus least, not just averaged ratings
- Combines a quantitative core (recommendation score, matrix ratings on wait time/communication/respect) with an open-ended long-text question and screening questions like visit reason and time waited, giving both breadth and depth
- Automated per-response quality scoring and an auto-generated report mean practice managers get analysis-ready output instead of raw spreadsheet data to sort through manually
Jotform
Create Free Patient Feedback Forms - Patient Feedback Form TemplatesThis is a template gallery/category page offering multiple static patient feedback form layouts rather than a single fielding-ready survey. It's built for quick deployment and easy customization via Jotform's drag-and-drop builder, useful for clinics wanting a fast, no-frills intake of feedback.
優れている点
- Wide selection of pre-built form layouts to choose from
- Familiar drag-and-drop form builder for quick customization
- Likely supports embedding on clinic websites or kiosks
物足りない点
- Static form fields only — no adaptive follow-up questioning to probe why a patient rated something poorly
- No mention of automated per-response quality scoring or auto-generated analysis reports
- No transparent methodology for how responses are interpreted or prioritized
Typeform
Patient Feedback Form TemplateA single conversational-style template focused on collecting patient feedback with Typeform's signature one-question-at-a-time UX. It's designed for a pleasant respondent experience but relies on fixed question paths rather than dynamic follow-up.
優れている点
- Polished, conversational one-question-at-a-time interface likely improves completion rates
- Easy to customize branding and question wording
- Simple to deploy via link or embed
物足りない点
- No adaptive AI interviewing — logic branching is rule-based, not a dynamic conversational probe into a specific visit moment
- No built-in best-worst prioritization exercise for improvement areas
- No automated quality scoring or auto-generated insights report
SurveyMonkey
Patient Satisfaction Survey TemplateA dedicated post-visit patient satisfaction template covering standard experience metrics, positioned similarly to our use case. It benefits from SurveyMonkey's established analytics and benchmarking tools, but the question set appears fixed rather than adaptive.
優れている点
- Purpose-built for post-visit satisfaction tracking, directly comparable in scope
- Backed by SurveyMonkey's broader analytics dashboards and benchmarking data
- Likely offers straightforward multi-channel distribution (email, link, embed)
物足りない点
- No adaptive AI follow-up to dig into the specific moment behind a low or high recommendation score
- No max-diff-style prioritization built into the template as described
- No transparent per-response quality scoring mechanism mentioned
よくあるご質問
「Patient Visit Experience & Care Feedback 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12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 feedback on your recent visit. Your honest answers help our care team improve —…」・「How likely are you to recommend this clinic to family or friends?」・「Thinking about your most recent visit, how would you rate each of the following?」。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、12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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