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Medical Clearance Process Experience Survey

Captures how patients experience the medical clearance process — for surgery, sports participation, return to work, or travel — from scheduling through receiving the final decision. An AI follow-up interview digs into the moments that created confusion or delay, giving clinics concrete detail behind satisfaction scores.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to share your recent experience getting medical clearance. Your honest feedback helps us make the process clearer and faster for future patients. About 4-5 minutes.

Q02
Multiple ChoiceRequired

What type of medical clearance did you most recently go through?

  • Pre-surgical clearance
  • Sports or athletic participation clearance
  • Return-to-work clearance
  • Travel or immigration clearance
  • Clearance for a procedure or treatment
  • Other
Q03
Opinion ScaleRequired

Before your appointment, how clear were you on what documents, tests, or steps the clearance would require?

Scale: 1 – 7
Min:Not clear at allMax:Extremely clear
Q04
Rating ScaleRequired

How easy was it to schedule your clearance appointment?

Range: 1 – 5
Min:Very difficultMax:Very easy
Q05
MatrixRequired

Thinking about the clearance visit itself, how much do you agree with each statement?

4 rows × 5 columns
  • The provider explained my results in terms I understood
  • Staff answered my questions thoroughly
  • I was told a clear timeline for when I'd get the final decision
  • I felt the clearance decision was based on a thorough evaluation
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
Multiple ChoiceRequired

From your first appointment to receiving the final clearance decision, how long did the whole process take?

  • Same day
  • 2-3 days
  • About a week
  • 2-3 weeks
  • Longer than 3 weeks
  • Still waiting
Q07
Multiple Choice

Did any of the following slow down or complicate your clearance? Select all that apply.

  • Scheduling delays
  • Missing paperwork or records
  • Needing additional tests
  • Unclear instructions
  • Insurance or billing issues
  • Difficulty reaching the office for updates
  • None of these
Q08
Opinion ScaleRequired

How confident are you that the final clearance decision was the right one for your situation?

Scale: 1 – 10
Min:Not at all confidentMax:Completely confident
Q09
AI Interview

Reconstruct the specific moment in this respondent's clearance journey that most shaped their confidence and timeline ratings — for example a delay, an unclear explanation, or an unexpected extra test. Ask what happened, how it was (or wasn't) resolved, and what the office could have done differently. If they reported low confidence in the decision, probe exactly what left them unsure; if they reported a smooth, fast process, ask what specifically made it work well so it can be repeated.

Q10
Opinion ScaleRequired

How likely are you to recommend this clinic or provider to someone who needs a similar clearance?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q11
Multiple Choice

What is your age range?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q12
Multiple Choice

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
Message

That's everything — thank you for sharing your experience! Your responses will be used to identify where the clearance process needs to be faster and clearer for future patients.

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 clearance journey — scheduling, the appointment itself, and time-to-decision — across all major clearance types (surgery, sports, return to work, travel), not just one use case
  • Uses an AI follow-up interview to reconstruct the specific moment that created confusion or delay, turning a satisfaction score into a concrete, actionable story
  • Combines quantitative measures (opinion scales, ratings, a matrix of agreement statements) with open-ended AI probing, so clinics get both benchmarkable metrics and qualitative detail
  • Automated per-response quality scoring and auto-generated reports mean clinics don't have to manually read every transcript to find the friction points

Jotform

Medical Clearance Form Template

This is a static, fillable clearance form intended to document a patient's fitness-for-activity sign-off (e.g., for a physician to complete), not a survey measuring the patient's experience of the clearance process. It's a documentation tool rather than a fielding-ready experience/satisfaction survey.

What it does well

  • Simple, familiar drag-and-drop form builder for quickly producing a clearance document
  • Widely used template library across many healthcare form types
  • Easy to distribute and collect signatures/uploads for clearance paperwork

Where it falls short

  • A static form with fixed fields — no adaptive follow-up questioning to explore why a delay or confusion happened
  • No mechanism to probe the specific moment in a patient's journey that caused friction
  • No automated quality scoring or synthesized reporting on patient experience themes

SurveySparrow

Free Printable Medical Clearance Form Template For Surgery

A printable clearance form scoped specifically to surgery, designed to document clearance decisions rather than survey patients about their experience going through the process. It's positioned as a free, printable asset, not an interactive experience-tracking survey.

What it does well

  • Free and easy to access/print
  • Purpose-built for the surgical clearance use case
  • Simple format that's quick for staff to implement

Where it falls short

  • Limited to surgery — doesn't cover sports, return-to-work, or travel clearance journeys
  • Static question set only; no adaptive AI interview to dig into specific delay or confusion moments
  • No per-response quality scoring or automatic report generation on patient sentiment

QuestionPro

Medical Examination Services Survey Template

A genuine patient-facing survey template around medical examination services, making it a closer comparison than the two form templates above, though it's framed broadly around exam services rather than the specific clearance-decision journey (scheduling through final decision). It appears to be a standard fixed-question survey rather than one built around any single clearance-type scenario.

What it does well

  • Established survey platform with broad customization and distribution options
  • Covers general medical examination service satisfaction, which overlaps with parts of the clearance experience
  • Comes with reporting/analytics tooling typical of QuestionPro's platform

Where it falls short

  • No adaptive AI follow-up interview to reconstruct the specific moment that caused delay or confusion
  • Not scoped to the clearance decision journey specifically (scheduling → appointment → final decision) across surgery/sports/work/travel contexts
  • No transparent, per-response AI quality scoring of open-ended feedback

Ready to launch?

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