Q01
Message
All templatesHealthcare & Clinical
Post-Visit Patient Experience & NPS Survey
Measures patient satisfaction across scheduling, wait times, provider interaction, and telehealth quality using NPS and multi-dimensional experience scales for healthcare organizations seeking actionable improvement insights.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
22 questions · ~10 min
Q02
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
Q03
Multiple Choice
What type of visit was your most recent appointment?
- In person (at clinic or hospital)
- Video/telehealth (with video)
- Phone (audio only)
Q04
Message
We'd like you to think about your interaction with your provider during your most recent visit. Please indicate how much you agree or disagree with each of the following statements.
Q05
Opinion Scale
Overall, how satisfied are you with your most recent healthcare visit?
Scale: 1 – 7
Min:Very dissatisfiedMax:Very satisfied
Q06
Message
Finally, a few optional questions about you for analysis purposes.
Q07
Message
Thank you for completing this survey. Your feedback is valuable and will be used to improve the care experience for all patients.
Q08
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
Q09
Opinion Scale
How satisfied were you with the wait time before your appointment began?
Scale: 1 – 7
Min:Very dissatisfiedMax:Very satisfied
Q10
Opinion Scale
My provider listened carefully to my concerns.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q11
Opinion Scale
How likely are you to recommend this clinic or provider to a friend or family member?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q12
Dropdown
What is your age group?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
- Prefer not to say
Q13
Opinion Scale
How easy or difficult was it to schedule your appointment?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q14
Opinion Scale
If your visit used phone or video, how would you rate the overall technology experience (audio quality, video clarity, ease of connecting)? If your visit was in person, please skip this question.
Scale: 1 – 7
Min:Very poorMax:Excellent
Q15
Opinion Scale
My provider explained things in a way I could understand.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q16
Long Text
Please share one thing that went well and one thing that could be improved about your visit.
Q17
Multiple Choice
Which gender do you identify with?
- Woman
- Man
- Non-binary
- Prefer not to say
Q18
Opinion Scale
My provider treated me with courtesy and respect.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q19
AI Interview
Based on your responses, we'd like to explore your visit experience a bit further. Please share your thoughts in a brief conversation.
Q20
Dropdown
In which country or region do you currently live?
- United States
- Canada
- United Kingdom
- Australia
- Germany
- France
- India
- Other (please specify)
- Prefer not to say
Q21
Opinion Scale
My provider involved me in decisions about my care.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q22
Opinion Scale
How clear were your next steps (e.g., medications, tests, follow-up appointments) after the visit?
Scale: 1 – 7
Min:Very unclearMax:Very clear
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
- Combines a traditional NPS question with multi-dimensional experience scales covering scheduling ease, wait-time satisfaction, telehealth technology quality, and specific provider-interaction dimensions (listening, clarity, respect, involvement in decisions) in one flow
- Includes an AI follow-up interview that adaptively probes based on each respondent's prior answers, going beyond fixed-choice questions to surface why scores were given
- Pairs quantitative scales with an open-text question for qualitative feedback and optional demographic questions (age, gender, region) placed at the end so they don't burden the core experience questions
- Uses chat-message framing throughout to explain survey sections, keeping the flow transparent and reducing respondent drop-off
Jotform
Dental Patient Experience Survey Form TemplateA ready-to-field form template focused specifically on dental patient experience rather than general healthcare visits. It's built on Jotform's drag-and-drop form builder, so it's easy to customize fields and branding, but it uses static form logic rather than survey-specific scaling methodology. Useful as a dental-specific starting point, not a general post-visit NPS instrument.
What it does well
- Fielding-ready template that can be customized quickly via Jotform's form builder
- Benefits from Jotform's broader integrations (payments, e-signatures, notifications) if a clinic already uses the platform
- Dental-specific framing may resonate well with dental practices specifically
Where it falls short
- Static form questions with no adaptive follow-up — cannot probe further into a low satisfaction score
- No voice AI interview or guided screen-share task option for richer qualitative context
- Narrower scope (dental only) versus a general medical/telehealth visit experience survey
SurveyMonkey
Patient Satisfaction Survey TemplateA fielding-ready post-visit patient satisfaction template from an established survey platform, directly comparable in intent to our NPS/experience survey. It likely benefits from SurveyMonkey's broad distribution and reporting tools, but the questions themselves are fixed multiple-choice/rating items. There's no indication of AI-driven follow-up or per-response quality scoring.
What it does well
- Backed by a mature, widely-used survey platform with strong distribution and basic analytics
- Template is purpose-built for post-visit patient satisfaction, aligning closely with common healthcare NPS use cases
- Likely quick to deploy for teams already using SurveyMonkey
Where it falls short
- No adaptive AI follow-up questions — all respondents see the same fixed question set regardless of answers
- No automated per-response quality scoring or transparent prompt methodology published
- No voice AI interview or guided task/screen-share option for deeper qualitative insight
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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