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Patient Satisfaction Survey: Pain, Communication & Discharge

Collect patient feedback on pain control, provider communication, and discharge readiness with this customizable patient visit satisfaction survey template.

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
Dropdown
When was your most recent healthcare visit?
  • In the last 7 days
  • 8–14 days ago
  • 15–30 days ago
  • 1–3 months ago
  • More than 3 months ago
Q2
Multiple Choice
What type of visit was it?
  • Emergency department
  • Inpatient hospital stay (overnight)
  • Outpatient clinic or urgent care
  • Telehealth/virtual visit
Q3
Rating
Overall, how would you rate the care you received during this visit?
Scale: 11 (star)
Min: PoorMax: Excellent
Q4
Multiple Choice
Did you have pain during this visit?
  • Yes
  • No
Q5
Matrix
Please rate your agreement with the following statements about pain management during this visit:
RowsStrongly disagreeDisagreeNeutralAgreeStrongly agreeNot applicable
My pain was well controlled.••••••
Staff responded quickly when I reported pain.••••••
I was asked about my pain regularly.••••••
Q6
Multiple Choice
Which methods were used to manage your pain? Select all that apply. If you had no pain, choose "None".
  • Oral medication
  • IV or injection medication
  • Ice or heat
  • Positioning or movement
  • Relaxation or breathing techniques
  • Other
  • None
Q7
Opinion Scale
How well did staff listen to you during this visit?
Range: 1 – 10
Min: Not at allMax: Completely
Q8
Rating
How clear was the information you received about your condition or care?
Scale: 11 (star)
Min: Very unclearMax: Very clear
Q9
Multiple Choice
Did staff give you enough time to ask questions?
  • Yes, definitely
  • Yes, somewhat
  • No
Q10
Multiple Choice
Attention check: To help us ensure data quality, please select "No".
  • Yes
  • No
Q11
Matrix
Before you left, how much did you agree with the following?
RowsStrongly disagreeDisagreeNeutralAgreeStrongly agreeNot applicable
I understood my medications and doses.••••••
I knew symptoms or side effects to watch for.••••••
I knew any activity or diet limits.••••••
I knew who to contact with questions.••••••
Q12
Opinion Scale
How confident did you feel managing your care after discharge?
Range: 1 – 10
Min: Not at all confidentMax: Very confident
Q13
Multiple Choice
Which supports did you receive before leaving? Select all that apply.
  • Written instructions provided
  • Demonstration or teach-back used
  • Follow-up appointment scheduled
  • Prescription(s) arranged before leaving
  • Transportation support provided
  • Home care or community support arranged
  • None of the above
  • Not applicable
Q14
Multiple Choice
What is your age group?
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65–74
  • 75 or older
  • Prefer not to say
Q15
Multiple Choice
How do you describe your gender? Select all that apply.
  • Woman
  • Man
  • Non-binary
  • Another gender identity
  • Prefer not to say
Q16
Multiple Choice
What is your current employment status?
  • Employed full-time
  • Employed part-time
  • Self-employed
  • Unemployed
  • Student
  • Retired
  • Unable to work
  • Prefer not to say
Q17
Long Text
What could we have done to improve your experience during this visit?
Max 600 chars
Q18
AI Interview
AI Interview: 2 Follow-up Questions on your visit
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Reference questions: 12
Q19
Chat Message
Thank you for completing this survey.

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