Patient Visit Experience & Satisfaction Survey Template

Collect post-visit feedback on scheduling, wait times, care quality, telehealth tech, and provider rapport. Drive patient satisfaction. 6–8 minutes.

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

Template Overview

Questions

AI-Powered

Smart Analysis

Ready-to-Use

Launch in Minutes

This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.

Sample Survey Items

Dropdown

When was your most recent healthcare appointment?

Within the last 7 days
8–30 days ago
1–3 months ago
3–6 months ago
More than 6 months ago

Multiple Choice

How did you schedule that appointment?

Phone call to the clinic
Patient portal or mobile app
Clinic or health system website (online form)
In person at the clinic
My provider/clinic scheduled it for me
Other

Opinion Scale

How easy or difficult was it to schedule your appointment?

Range: 1 – 10

Min: Very difficultMid: Neither easy nor difficultMax: Very easy

Multiple Choice

What type of visit was your most recent appointment?

In person (at clinic or hospital)
Video/telehealth (with video)
Phone (audio only)

Matrix

If your visit used phone or video, how would you rate the technical aspects? If it was in person, select Not applicable for each row.

Rows	Very poor	Poor	Fair	Good	Excellent	Not applicable
Audio clarity	•	•	•	•	•	•
Video clarity	•	•	•	•	•	•
Connection stability	•	•	•	•	•	•
Ease of joining the visit	•	•	•	•	•	•
Overall technical experience	•	•	•	•	•	•

Multiple Choice

Attention check: To confirm attention, please select "I am paying attention" below.

I am paying attention
I am not paying attention
Prefer not to answer

Matrix

Thinking about your most recent appointment, how much do you agree or disagree with each statement?

Rows	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
I felt listened to.	•	•	•	•	•
I was treated with respect.	•	•	•	•	•
Explanations were easy to understand.	•	•	•	•	•
We decided on a plan together.	•	•	•	•	•
I had enough time for questions.	•	•	•	•	•

Opinion Scale

How clear were your next steps (e.g., medications, tests, follow-up) after the visit?

Range: 1 – 10

Min: Very unclearMid: Neither clear nor unclearMax: Very clear

Opinion Scale

How likely are you to recommend this clinic or provider to others?

Range: 1 – 10

Min: Not at all likelyMid: NeutralMax: Extremely likely

Q10

Long Text

Please share one thing that went well and one thing to improve.

Max 600 chars

Q11

Dropdown

What is your age group?

18–24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say

Q12

Multiple Choice

Which gender do you identify with?

Woman
Man
Non-binary
Prefer not to say

Q13

Short Text

Country or region where you live:

Max 100 chars

Q14

Dropdown

What is the highest level of education you have completed?

Less than high school
High school or equivalent
Some college or associate degree
Bachelor’s degree
Postgraduate or professional degree
Prefer not to say

Q15

Multiple Choice

What is your current employment status?

Employed full-time
Employed part-time
Self-employed
Unemployed
Student
Homemaker/caregiver
Retired
Prefer not to say

Q16

Chat Message

Welcome! Please answer based on your most recent healthcare appointment. There are no right or wrong answers.

Q17

Long Text

Is there anything else you would like us to know about your experience?

Max 600 chars

Q18

AI Interview

AI Interview: 2 Follow-up Questions on your visit experience

AI InterviewLength: 2Personality: [Object Object]Mode: Fast

Q19

Chat Message

Thank you for completing the survey. Your feedback helps improve patient care.

Frequently Asked Questions

What is QuestionPunk?

QuestionPunk is a lightweight survey platform for live AI interviews you control. It's fast, flexible, and scalable—adapting every question in real time, moderating responses across languages, letting you steer prompts, models, and flows, and even generating surveys from a simple prompt. Get interview-grade insight with survey-level speed across qual and quant.

How do I create my first survey?

Sign up, then decide how you want to build: let the AI generate a survey from your prompt, pick a template, or start from scratch. Choose question types, set logic, and preview before sharing.

How can I share surveys with my team?

Send a project link so teammates can view and collaborate instantly.

Can the AI generate a survey from a prompt?

Yes. Provide a prompt and QuestionPunk drafts a survey you can tweak before sending.

How long does support typically take to reply?

We reply within 24 hours—often much sooner. Include key details in your message to help us assist you faster.

Can I export survey results?

Absolutely. Export results as CSV straight from the results page for quick data work.

Healthcare