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Patient Experience Survey Template: Support & Education

Collect healthcare patient feedback on post-visit support, education, and care coordination. Customize this template to boost satisfaction and outcomes.

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
When was your most recent healthcare visit?
  • Within the last 30 days
  • 1-3 months ago
  • 3-6 months ago
  • 6-12 months ago
  • More than 12 months ago
  • I have not had a visit in the past 12 months
Q2
Multiple Choice
What type of care setting did you visit most recently?
  • Primary care / family medicine
  • Specialist clinic
  • Hospital outpatient clinic
  • Emergency or urgent care
  • Telehealth/virtual visit
  • Behavioral or mental health
  • Other
Q3
Rating
How easy was it to reach the care team when you needed help?
Scale: 10 (star)
Min: Very hardMax: Very easy
Q4
Multiple Choice
Which support channels did you use to get help? Select all that apply.
  • Phone call
  • Patient portal messages
  • Email
  • Text/SMS
  • In-person nurse line or walk-in
  • 24/7 helpline
  • Support group or peer navigator
  • None of the above
  • Other
Q5
Opinion Scale
The explanations about my condition and treatment were clear.
Range: 1 – 10
Min: Strongly disagreeMid: Neither agree nor disagreeMax: Strongly agree
Q6
Matrix
How useful were the following resources during or after your visit?
RowsDid not useNot usefulSlightly usefulModerately usefulVery useful
Verbal explanations from clinicians•••••
Written handouts or after-visit summary•••••
Online resources recommended by staff•••••
Patient portal instructions or messages•••••
Videos or illustrations•••••
Q7
Multiple Choice
Were your questions answered in a way you could understand?
  • Yes, completely
  • Yes, somewhat
  • No
  • I did not have questions
Q8
Opinion Scale
Different providers seemed to share information effectively.
Range: 1 – 10
Min: Strongly disagreeMid: Neither agree nor disagreeMax: Strongly agree
Q9
Multiple Choice
Before you left, did you have a clear plan for next steps?
  • Yes, a written plan
  • Yes, a verbal plan only
  • Partly
  • No
  • Not applicable
Q10
Numeric
Approximately how many days passed between a referral and the appointment you most recently attended? Enter 0 if not applicable.
Accepts a numeric value
Whole numbers only
Q11
Rating
How confident are you in managing your health after the visit?
Scale: 10 (star)
Min: Not at all confidentMax: Very confident
Q12
Opinion Scale
How likely are you to recommend this clinic or care team to a friend or family member?
Range: 1 – 10
Min: Not at all likelyMid: Neither likely nor unlikelyMax: Extremely likely
Q13
Short Text
What went particularly well during your most recent visit?
Max 100 chars
Q14
Multiple Choice
Attention check: To confirm you are paying attention, please select "Yes".
  • Yes
  • No
Q15
Dropdown
What is your age?
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65-74
  • 75+
  • Prefer not to say
Q16
Multiple Choice
Which best describes your gender?
  • Woman
  • Man
  • Non-binary
  • Another identity
  • Prefer not to say
Q17
Dropdown
Where do you live?
  • United States
  • Canada
  • United Kingdom
  • Australia
  • India
  • Other
  • Prefer not to say
Q18
Dropdown
What is the highest level of education you have completed?
  • Less than high school
  • High school or equivalent
  • Some college or technical training
  • Bachelor’s degree
  • Graduate or professional degree
  • Prefer not to say
Q19
Multiple Choice
What is your current employment status?
  • Employed full-time
  • Employed part-time
  • Self-employed
  • Student
  • Homemaker/caregiver
  • Unemployed
  • Retired
  • Unable to work
  • Prefer not to say
Q20
Multiple Choice
Do you live with any ongoing health conditions? Select all that apply.
  • Diabetes
  • Heart or circulatory condition
  • Respiratory condition (e.g., asthma, COPD)
  • Mental health condition
  • Musculoskeletal or pain condition
  • Neurological condition
  • None of the above
  • Other
  • Prefer not to say
Q21
Chat Message
Welcome! This brief survey (about 5 minutes) asks about your most recent healthcare visit within the past 12 months. Please answer based on that single visit. Your responses are confidential and reported in aggregate.
Q22
Long Text
Is there anything else we could improve about support, education, or care coordination?
Max 600 chars
Q23
AI Interview
AI Interview: 2 Follow-up Questions on Your Visit Experience
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast
Q24
Chat Message
Thank you for completing the survey. Your feedback helps us improve patient care.

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