Patient-Provider Fit & Care Preferences Survey Template
Evaluate patient-provider fit, care needs, and preferences. Customizable healthcare survey template to improve matching and outcomes. 6–8 minutes. Start now.
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
27
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
Q1
Multiple Choice
Have you seen a healthcare provider for your own care in the past 6 months?
Yes
No
Q2
Multiple Choice
If No: Which reasons apply? Select all that apply.
Could not get an appointment
No need for care
Cost or coverage concerns
Transportation or distance
Unsure where to go
Other
Q3
Multiple Choice
What type of provider did you most recently see?
Primary care
Specialist
Mental health professional
OB/GYN
Urgent care or retail clinic
Telehealth clinician
Other
Prefer not to say
Q4
Multiple Choice
How did you choose this provider? Select all that apply.
Referred by another clinician
Chose from insurance network list
Friend or family recommendation
Online reviews or search
Assigned by clinic or insurer
I already knew this provider
Other
Q5
Numeric
In the past 6 months, how many visits did you have with this provider?
Accepts a numeric value
Whole numbers only
Q6
Opinion Scale
Overall, how well did this provider fit your needs and preferences?
Range: 1 – 10
Min: Very poor fitMid: NeutralMax: Excellent fit
Q7
Multiple Choice
If there were mismatches, which applied? Select all that apply.
Clinical approach not aligned
Limited appointment times
Communication style didn’t suit me
Language barrier
Cultural sensitivity lacking
Location or travel inconvenient
Insurance or benefits issues
Provider gender preference not met
Costs higher than expected
No mismatches
Other
Q8
Opinion Scale
How easy was it to get an appointment that met your needs?
Range: 1 – 10
Min: Very difficultMid: NeutralMax: Very easy
Q9
Matrix
Please rate your agreement with the following about this visit.
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I felt listened to
•
•
•
•
•
My cultural background was respected
•
•
•
•
•
We discussed my preferences
•
•
•
•
•
Information was clear
•
•
•
•
•
My language needs were met
•
•
•
•
•
Q10
Multiple Choice
Do you plan to continue with this provider for similar needs?
Yes
No, I plan to switch
Unsure
Q11
Long Text
What, if anything, would have improved the fit between this provider and your needs?
Max 600 chars
Q12
Matrix
How important are these when choosing a provider?
Rows
Not important
Slightly important
Moderately important
Very important
Extremely important
Clinical expertise in my condition
•
•
•
•
•
Accepts my insurance
•
•
•
•
•
Communication style
•
•
•
•
•
Cultural understanding
•
•
•
•
•
Language alignment
•
•
•
•
•
Appointment availability
•
•
•
•
•
Proximity or telehealth access
•
•
•
•
•
Q13
Multiple Choice
How would you prefer to search for well‑matched providers?
Insurance directory with filters
Independent review site
Clinician referral
Community organization recommendations
Personalized matching app
Other
Q14
Rating
How confident are you that you can find a well‑matched provider when needed?
Scale: 11 (star)
Min: Not at all confidentMax: Extremely confident
Q15
Multiple Choice
Attention check: To confirm you are paying attention, please select “I agree.”
I agree
I do not agree
Q16
Long Text
Anything else we should know about matching you to providers?
Max 600 chars
Q17
Dropdown
What is your age?
18–24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say
Q18
Multiple Choice
Which gender best describes you?
Woman
Man
Non-binary
Prefer not to say
Q19
Multiple Choice
What is your highest level of education?
Less than high school
High school or equivalent
Some college
Associate degree
Bachelor’s degree
Graduate or professional degree
Prefer not to say
Q20
Multiple Choice
What is your current employment status?
Full-time
Part-time
Self-employed
Unemployed
Student
Retired
Unable to work
Prefer not to say
Q21
Multiple Choice
How do you primarily pay for healthcare?
Employer-sponsored insurance
Individual or marketplace plan
Medicare
Medicaid or public program
Military/VA
Uninsured or self-pay
Prefer not to say
Q22
Multiple Choice
Preferred language for receiving care?
English
Spanish
Chinese
Another language
Prefer not to say
Q23
Short Text
Country or region where you usually receive care:
Max 100 chars
Q24
Chat Message
Welcome! This survey asks about a recent healthcare visit and what matters to you when choosing providers. Please answer based on your own care in the past 6 months if applicable.
Q25
Long Text
Any final comments or examples about patient–provider fit you’d like to share?
Max 600 chars
Q26
AI Interview
AI Interview: 2 Follow-up Questions on patient–provider fit
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q27
Chat Message
Thank you for your time—your feedback will help improve patient–provider matching.
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.