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Healthcare Patient Visit Satisfaction Survey Template

Use this patient experience survey to assess appointment access, clinician communication, and follow-up, then improve care quality and streamline visits.

What's Included

AI-Powered Questions

Intelligent follow-up questions based on responses

Automated Analysis

Real-time sentiment and insight detection

Smart Distribution

Target the right audience automatically

Detailed Reports

Comprehensive insights and recommendations

Sample Survey Items

Q1
Multiple Choice
What type of visit is this about?
  • Primary care
  • Specialist
  • Urgent care
  • Telehealth/video visit
  • Nurse-only visit
  • Other
Q2
Dropdown
When did this visit occur?
  • Within the past 7 days
  • 8–30 days ago
  • 31–90 days ago
  • 3–12 months ago
  • More than a year ago
Q3
Opinion Scale
Thinking about this visit, how easy was it to reach the office to schedule or ask a question (if needed)?
Range: 1 – 10
Min: Very difficultMid: Neither easy nor difficultMax: Very easy
Q4
Multiple Choice
How did you contact the clinic before or after the visit? Select all that apply.
  • Phone call
  • Patient portal/message
  • Email
  • Clinic website form
  • Mobile app
  • Text/SMS
  • Walk-in
  • Did not contact the clinic
  • Other
Q5
Matrix
Thinking about the clinician you saw at this visit, how much do you agree with each statement?
RowsStrongly disagreeDisagreeNeither agree nor disagreeAgreeStrongly agree
Made me feel comfortable•••••
Listened attentively•••••
Showed respect and empathy•••••
Explained in a way I could understand•••••
Involved me in decisions about my care•••••
Q6
Opinion Scale
How clear were your next steps after the visit (for example, medications, tests, or self-care)?
Range: 1 – 10
Min: Not at all clearMid: Somewhat clearMax: Extremely clear
Q7
Multiple Choice
Which follow-up elements did you receive or understand? Select all that apply.
  • Written after-visit summary
  • Instructions via patient portal/message
  • When to return or the follow-up plan
  • Who to contact with questions
  • Medication directions were clear
  • Test results arrived when expected
  • I did not need any follow-up
  • I am still waiting for follow-up
Q8
Rating
Overall, how would you rate your experience with this visit?
Scale: 10 (star)
Min: Very poorMax: Excellent
Q9
Multiple Choice
Attention check: To confirm you are paying attention, please select “Agree.”
  • Strongly disagree
  • Disagree
  • Neutral
  • Agree
  • Strongly agree
Q10
Dropdown
What is your age?
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65 or older
  • Prefer not to say
Q11
Multiple Choice
Which gender do you identify with?
  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q12
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
Q13
Multiple Choice
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
Q14
Short Text
Which country or region do you live in?
Max 100 chars
Q15
Long Text
Any other comments or suggestions you would like to share?
Max 600 chars
Q16
AI Interview
AI Interview: 2 Follow-up Questions about your visit
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast
Q17
Chat Message
Thank you for your time—your feedback helps improve care.

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