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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

Sample Survey Items

Q1
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
Q2
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
Q3
Opinion Scale
How easy or difficult was it to schedule your appointment?
Range: 1 – 10
Min: Very difficultMid: Neither easy nor difficultMax: Very easy
Q4
Multiple Choice
What type of visit was your most recent appointment?
  • In person (at clinic or hospital)
  • Video/telehealth (with video)
  • Phone (audio only)
Q5
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.
RowsVery poorPoorFairGoodExcellentNot applicable
Audio clarity••••••
Video clarity••••••
Connection stability••••••
Ease of joining the visit••••••
Overall technical experience••••••
Q6
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
Q7
Matrix
Thinking about your most recent appointment, how much do you agree or disagree with each statement?
RowsStrongly disagreeDisagreeNeither agree nor disagreeAgreeStrongly 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.•••••
Q8
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
Q9
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.

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