Q01
Message
All templatesHealthcare & Clinical
Patient Visit Experience: Pain, Communication & Discharge
Measures patient satisfaction across pain management, provider communication, and discharge preparedness for inpatient, outpatient, emergency, and telehealth visits.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
25 questions · ~11 min
Q02
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
Q03
Multiple Choice
Did you experience pain during this visit?
- Yes
- No
Q04
Opinion Scale
How well did healthcare staff listen to your concerns during this visit?
Scale: 1 – 7
Min:Not at all wellMax:Extremely well
Q05
Opinion Scale
Before I left, I clearly understood my discharge or after-visit instructions.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q06
Opinion Scale
Overall, how would you rate the quality of care you received during this visit?
Scale: 1 – 7
Min:Very poorMax:Excellent
Q07
Dropdown
What is your age group?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65–74
- 75 or older
- Prefer not to say
Q08
Message
Thank you for completing this survey. Your feedback helps us improve the quality of care we provide. Your responses are confidential and will be reviewed in aggregate. If you have an urgent medical concern, please contact your healthcare provider directly.
Q09
Multiple Choice
What type of healthcare visit was it?
- Emergency department
- Inpatient hospital stay (overnight)
- Outpatient clinic or urgent care
- Telehealth / virtual visit
- Other (please specify)
Q10
Opinion Scale
Healthcare staff took my pain seriously during this visit.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q11
Opinion Scale
How clear was the information you received about your condition or treatment plan?
Scale: 1 – 7
Min:Not at all clearMax:Extremely clear
Q12
Opinion Scale
I understood what medications to take and when to take them.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q13
Opinion Scale
How likely are you to recommend this healthcare facility to a friend or family member?
Scale: 1 – 7
Min:Not at all likelyMax:Extremely likely
Q14
Multiple Choice
How do you describe your gender? Select all that apply.
- Woman
- Man
- Non-binary
- Another gender identity
- Prefer not to say
Q15
Opinion Scale
Staff responded promptly when I reported pain.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q16
Multiple Choice
Did healthcare staff give you enough time to ask questions?
- Yes, definitely
- Yes, somewhat
- No
Q17
Opinion Scale
I knew what warning signs or symptoms to watch for after leaving.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q18
Long Text
Based on your responses in this survey, please share any additional thoughts or feelings about your visit experience.
Q19
Dropdown
What is your current employment status?
- Employed full-time
- Employed part-time
- Self-employed
- Unemployed
- Student
- Retired
- Unable to work
- Prefer not to say
Q20
Opinion Scale
My pain was well controlled during this visit.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q21
Opinion Scale
I knew who to contact if I had questions or concerns after leaving.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q22
AI Interview
Thank you for your written feedback. We'd like to ask a couple of brief follow-up questions to better understand your experience.
Q23
Multiple Choice
Which methods were used to manage your pain? Select all that apply.
- Oral medication
- IV or injection medication
- Ice or heat
- Positioning or movement
- Relaxation or breathing techniques
- Other (please specify)
- None of the above
Q24
Opinion Scale
How confident did you feel managing your health after leaving?
Scale: 1 – 7
Min:Not at all confidentMax:Extremely confident
Q25
Multiple Choice
Which of the following 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
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
- Covers the full care journey in one instrument — visit type (inpatient/outpatient/ER/telehealth), pain management, provider communication, and discharge preparedness — rather than isolating a single stage like intake or discharge alone.
- Uses granular opinion-scale items (pain taken seriously, prompt response to pain, staff listening, clarity of information, understanding of medications/warning signs/follow-up contacts) to pinpoint exactly where experience breaks down.
- Pairs an open-text reflection question with an AI follow-up interview that probes deeper into whatever themes the patient raises, instead of ending data collection at a static free-text box.
- Adds demographic dropdowns (age, gender, employment) for segmentation and applies automated per-response quality scoring, giving cleaner, analysis-ready data than a plain form export.
SurveyMonkey
Patient Satisfaction Survey TemplateA ready-to-field, static post-visit satisfaction survey covering typical experience dimensions. It's a genuine comparable offering for this topic, built on SurveyMonkey's established survey infrastructure. It relies on fixed question sets rather than adaptive questioning.
What it does well
- Backed by a widely used, established survey platform with broad distribution options
- Pre-built template reduces setup time for a standard patient satisfaction study
- Likely supports basic branching/skip logic common to SurveyMonkey templates
Where it falls short
- Static question set with no adaptive AI follow-up to probe open-ended answers
- No voice-based interview option or guided screen-share tasks
- No automated per-response quality scoring or transparent prompt methodology
Typeform
Patient Discharge Form TemplateThis is primarily a discharge documentation form rather than a full patient-experience or satisfaction survey — it appears narrower in scope, focused on the discharge step rather than pain management and communication across visit types. Still relevant as a point of comparison for the discharge-preparedness portion of a patient feedback program.
What it does well
- Typeform's conversational, one-question-at-a-time interface is mobile-friendly and easy to complete
- Clean design likely improves completion rates for shorter discharge-focused forms
Where it falls short
- Narrow focus on discharge only, without coverage of pain management or in-visit communication
- Static form with no adaptive AI questioning or voice interview option
- No automated report generation or response-level quality scoring
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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