Q01
Message
All templatesHealthcare & Clinical
Patient Visit Satisfaction & Communication Survey
Assesses patient experience across scheduling access, clinician communication, post-visit follow-up, and overall satisfaction to identify actionable care quality improvements.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
22 questions · ~10 min
Q02
Multiple Choice
What type of visit is this feedback about?
- Primary care
- Specialist
- Urgent care
- Telehealth / video visit
- Nurse-only visit
- Emergency department
- Other
Q03
Opinion Scale
How easy was it to reach the clinic to schedule your visit or ask a question?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q04
Message
The following questions ask about the clinician you saw during this visit. Please indicate how much you agree or disagree with each statement.
Q05
Opinion Scale
How clear were the next steps you were given after your visit (e.g., medications, tests, or self-care instructions)?
Scale: 1 – 7
Min:Not at all clearMax:Extremely clear
Q06
Rating Scale
Overall, how would you rate your experience with this visit?
Range: 1 – 5
Min:Very poorMax:Excellent
Q07
Dropdown
What is your age?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
- Prefer not to say
Q08
Message
Thank you for completing this survey. Your feedback is valuable and will be used to improve the care experience for all patients.
Q09
Dropdown
When did this visit take place?
- Within the past 7 days
- 8–30 days ago
- 31–90 days ago
- 3–12 months ago
- More than a year ago
Q10
Multiple Choice
How did you contact the clinic before or after your visit? Select all that apply.
- Phone call
- Patient portal / online message
- Clinic website form
- Mobile app
- Text / SMS
- Walk-in
- Did not contact the clinic
- Other
Q11
Opinion Scale
The clinician listened carefully to me.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q12
Multiple Choice
Which of the following did you receive after your visit? Select all that apply.
- Written after-visit summary
- Instructions via patient portal or message
- A follow-up appointment or plan
- Contact information for questions
- Medication instructions
- Test results within the expected timeframe
- I did not need any follow-up
- I am still waiting for follow-up information
Q13
Opinion Scale
How likely are you to recommend this clinic to a friend or family member?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q14
Multiple Choice
What is your gender identity?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q15
Opinion Scale
The clinician explained things in a way I could understand.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q16
Long Text
Based on your responses, is there anything else you would like to share about your visit experience?
Q17
Dropdown
What is the highest level of education you have completed?
- Less than high school
- High school or equivalent
- Some college / Associate degree
- Bachelor's degree
- Postgraduate degree
- Prefer not to say
Q18
Opinion Scale
The clinician showed respect for what I had to say.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q19
AI Interview
Thank you for your responses so far. To help us better understand your experience, an AI moderator will ask a couple of brief follow-up questions.
Q20
Dropdown
What is your current employment status?
- Employed full-time
- Employed part-time
- Self-employed
- Student
- Unemployed
- Retired
- Not working for pay
- Prefer not to say
Q21
Opinion Scale
The clinician spent enough time with me.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q22
Opinion Scale
I felt involved in decisions about my care.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes dedicated opinion-scale questions on clinician listening, explanation clarity, respect, time spent, and involvement in care decisions — not just a single satisfaction score
- Uses an AI follow-up interview after the structured questions to let patients elaborate on their experience in their own words, going beyond a static open-text box
- Covers the full visit journey — scheduling access, contact channels, clinician communication, post-visit follow-up materials, and overall/NPS-style ratings — in one flow
- Separates demographic questions (age, gender identity, education, employment) at the end so they don't bias earlier responses, with transparent, auditable question logic throughout
SurveyMonkey
Patient Satisfaction Survey TemplateA ready-to-field template covering standard post-visit satisfaction topics. It's built on SurveyMonkey's established survey infrastructure with broad distribution and analytics options. Like most static templates, it relies on fixed question sets rather than adaptive probing.
What it does well
- Well-known, mature survey platform with reliable distribution and reporting tools
- Template is pre-built and ready to deploy quickly
- Likely benefits from SurveyMonkey's broad question-type library and benchmarking features
Where it falls short
- No adaptive AI follow-up questioning — all respondents see the same fixed question path
- No voice AI interview or screen-share task option for richer qualitative feedback
- No published methodology on how question wording or scoring logic was derived
SurveySparrow
Free Patient Satisfaction Survey TemplateA free, healthcare-specific patient satisfaction template with a conversational chat-style survey format. It's positioned as a quick-start template rather than an AI-driven interview experience. Good for basic feedback collection but limited for deeper qualitative follow-up.
What it does well
- Conversational, chat-like UI that can feel more engaging than a traditional form
- Healthcare-specific template framing tailored to patient satisfaction
- Free to use as a starting point
Where it falls short
- No adaptive AI-driven follow-up interviewing based on individual answers
- No automated per-response quality scoring
- No voice-based interview option for patients who prefer speaking over typing
Jotform
Patient Satisfaction Survey Form TemplateA customizable form-builder template for collecting patient satisfaction feedback, part of Jotform's large general-purpose template library. It's flexible for form design but is a static form product rather than an interview-style research tool. No indication of adaptive questioning or AI-driven analysis.
What it does well
- Highly customizable form fields and layout via Jotform's drag-and-drop builder
- Large ecosystem of integrations (payments, CRMs, notifications)
- Easy to embed on clinic websites or share via link
Where it falls short
- Static form structure with no adaptive AI follow-up questions
- No voice AI interview or guided screen-share task capability
- No automated quality scoring of open-text responses or auto-generated insight reports
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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