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Patient Experience Survey Template: Access & Communication

Collect feedback on appointment access, provider communication, and care quality with this patient experience survey template. Customize and deploy in 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
Chat Message
Welcome! This brief survey asks about your most recent visit in the past 6 months. It should take about 4–5 minutes. Your answers help us improve.
Q2
Dropdown
When was your most recent interaction with us?
  • Within the last 7 days
  • 2–4 weeks ago
  • 1–3 months ago
  • 3–6 months ago
Q3
Multiple Choice
What type of care did you receive most recently?
  • Primary care
  • Specialist visit
  • Urgent care
  • Telehealth/video visit
  • Message-only consult
  • Lab or imaging
  • Pharmacy/medication delivery
  • Other
Q4
Multiple Choice
How did you schedule or start that visit?
  • Website
  • Mobile app
  • Phone call
  • Walk-in
  • Referral link or email
  • Third-party marketplace
  • Other
Q5
Opinion Scale
Overall, how easy was it to get the care you needed?
Range: 1 – 10
Min: Very difficultMid: Neither easy nor difficultMax: Very easy
Q6
Numeric
About how many minutes did you wait past your scheduled time? Enter 0 if you were on time or seen early.
Accepts a numeric value
Whole numbers only
Q7
Matrix
Thinking about your most recent visit, how much do you agree with each statement?
RowsStrongly disagreeDisagreeNeither agree nor disagreeAgreeStrongly agree
Staff communicated clearly•••••
The clinician explained next steps•••••
I felt listened to•••••
My questions were answered•••••
My preferences were respected•••••
Q8
Multiple Choice
After your visit, did you receive timely follow-up or results?
  • Yes, within 24 hours
  • Yes, within 2–3 days
  • Yes, but later than 3 days
  • No follow-up was needed
  • No, I expected follow-up but did not receive it
Q9
Rating
Overall, how would you rate the clinician you saw?
Scale: 11 (star)
Min: PoorMax: Excellent
Q10
Opinion Scale
My main issue was resolved by this visit.
Range: 1 – 10
Min: Strongly disagreeMid: Neither agree nor disagreeMax: Strongly agree
Q11
Opinion Scale
How likely are you to recommend our care to a friend or family member?
Range: 1 – 10
Min: Not at all likelyMid: NeutralMax: Extremely likely
Q12
Multiple Choice
Which of these digital features did you use for this visit?
  • Online booking
  • Secure messaging
  • View lab results
  • Prescription refill
  • Payment/checkout
  • Order tracking for meds/devices
  • None of the above
Q13
Multiple Choice
How easy was the website or app to use for your needs?
  • Very easy
  • Somewhat easy
  • Neither easy nor difficult
  • Somewhat difficult
  • Very difficult
  • Did not use
Q14
Multiple Choice
Attention check: To confirm you’re paying attention, please select “I am paying attention.”
  • I am paying attention
  • I am not paying attention
  • Prefer not to say
Q15
Multiple Choice
What is your age group?
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q16
Multiple Choice
What is your gender?
  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q17
Dropdown
Where do you live?
  • United States
  • United Kingdom
  • Canada
  • Australia
  • European Union
  • Other country
  • Prefer not to say
Q18
Multiple Choice
What is the highest level of education you have completed?
  • Less than high school
  • High school or equivalent
  • Some college, no degree
  • 2-year degree
  • 4-year college degree
  • Postgraduate 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, looking
  • Unemployed, not looking
  • Retired
  • Unable to work
  • Prefer not to say
Q20
Long Text
What is one thing we could improve for patients like you?
Max 600 chars
Q21
AI Interview
AI Interview: 2 Follow-up Questions on Your Visit
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q22
Chat Message
Thank you for your feedback—your responses will help us improve care for patients like you.

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