Q01
Message
All templates
Patient-Provider Fit & Care Preference Assessment
Measures patient-provider alignment across clinical, communication, and access dimensions to identify mismatch drivers and care preferences. Designed for healthcare organizations, insurers, or researchers seeking to improve provider matching and patient retention.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
26 questions · ~11 min
Q02
Multiple Choice
Have you seen a healthcare provider for your own care in the past 6 months?
- Yes
- No
Q03
Multiple Choice
What type of healthcare provider did you most recently see?
- Primary care physician
- Specialist
- Mental health professional
- OB/GYN
- Urgent care or retail clinic
- Telehealth clinician
- Other (please specify)
- Prefer not to say
Q04
Opinion Scale
Overall, how well did this provider fit your healthcare needs?
Scale: 1 – 7
Min:Very poor fitMax:Excellent fit
Q05
Ranking
Please rank the following factors by how important they are to you when choosing a healthcare provider, from most to least important.
- Clinical expertise in my condition
- Communication style
- Cultural understanding
- Location or convenience
- Appointment availability
- Cost transparency
- Provider gender
Drag to rank
Q06
Long Text
What, if anything, would have improved the fit between you and this provider?
Q07
Dropdown
What is your age?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
- Prefer not to say
Q08
Message
Thank you for completing this survey. Your responses will help improve how patients are matched with healthcare providers. If you have any questions about this research, please contact the study team at the email provided in your invitation.
Q09
Multiple Choice
Which of the following reasons apply to why you have not seen a provider? 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 (please specify)
- Prefer not to say
Q10
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 (please specify)
Q11
Opinion Scale
How easy was it to get an appointment that met your scheduling needs?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q12
Multiple Choice
How would you most prefer to search for a well-matched provider?
- Insurance directory with filters
- Independent review site
- Clinician referral
- Community organization recommendations
- Personalized matching app or tool
- Other (please specify)
Q13
AI Interview
Based on your earlier responses, we'd like to explore your patient–provider fit experiences in a bit more depth. Please share your thoughts, and our moderator will ask a couple of follow-up questions.
Q14
Multiple Choice
Which gender best describes you?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q15
Dropdown
In the past 6 months, approximately how many visits did you have with this provider?
- 1
- 2
- 3–4
- 5–6
- 7 or more
- Unsure
Q16
Opinion Scale
This provider listened carefully to my concerns.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q17
Opinion Scale
How confident are you that you could find a well-matched provider if you needed one?
Scale: 1 – 7
Min:Not at all confidentMax:Extremely confident
Q18
Dropdown
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
Q19
Opinion Scale
This provider explained things in a way I could understand.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q20
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
Q21
Opinion Scale
This provider involved me in decisions about my care.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q22
Dropdown
What is your preferred language for receiving healthcare?
- English
- Spanish
- Chinese (Mandarin or Cantonese)
- Vietnamese
- Tagalog
- Arabic
- French
- Korean
- Another language
- Prefer not to say
Q23
Opinion Scale
This provider showed respect for my background and preferences.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q24
Dropdown
In which region do you usually receive healthcare?
- U.S. — Northeast
- U.S. — Southeast
- U.S. — Midwest
- U.S. — Southwest
- U.S. — West
- U.S. — Pacific (HI, AK)
- Canada
- United Kingdom
- European Union
- Other
- Prefer not to say
Q25
Multiple Choice
Which of the following, if any, were areas of mismatch with this provider? Select all that apply.
- Clinical approach not aligned with my preferences
- Limited appointment times
- Communication style didn't suit me
- Language barrier
- Cultural sensitivity lacking
- Location or travel inconvenient
- Insurance or billing issues
- Provider gender preference not met
- Costs higher than expected
- No mismatches
- Other (please specify)
Q26
Multiple Choice
Do you plan to continue seeing this provider for similar healthcare needs?
- Yes
- No, I plan to switch
- Unsure
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
- AI-powered follow-up questions dynamically explore patient concerns in depth, replacing shallow rating-only feedback with rich qualitative insight
- Academic-grade survey methodology with proper scale construction—no leading questions, no demographics-first bias, no unnecessary attention checks
- Full transparency: every AI prompt, model, and logic flow is visible to healthcare researchers for IRB review and replication studies
- Uniquely focused on site-level workload and data capture challenges—not just patient eCRF collection—filling a major gap in clinical trial operations research
- AI follow-ups adaptively probe coordinator pain points around data integrity, protocol deviations, and workflow bottlenecks in ways static forms cannot
SurveyMonkey
Post-Visit Patient Satisfaction Survey TemplateA well-established template with HIPAA-compliant features available on Enterprise plans. Offers expert-certified questions and CAHPS/AHRQ alignment, but limited to static question formats with no adaptive depth.
What it does well
- Expert-certified questions aligned with CAHPS and AHRQ standards
- HIPAA-compliant features on Enterprise plans with strong brand trust
- Multi-channel distribution via email, SMS, QR codes, and website embeds
Where it falls short
- No AI-powered follow-up questions to explore the reasons behind patient ratings
- HIPAA compliance requires expensive Enterprise plan—not accessible for academic researchers
- Static question flow cannot adapt to individual patient experiences or probe deeper into concerning responses
Typeform
Patient Satisfaction Survey TemplateTypeform's one-question-at-a-time UX creates a conversational feel, and they emphasize HIPAA compliance. However, the 'conversational' design is purely cosmetic—questions are still pre-scripted with no real adaptability.
What it does well
- Elegant conversational UI that presents one question at a time, reducing cognitive load
- HIPAA compliance and ISO27001 certification available on enterprise plans
- Strong integration ecosystem with 300+ tools for automated data routing
Where it falls short
- No AI follow-up capability—'conversational' is just UX styling, not actual dialogue
- HIPAA compliance requires enterprise plan pricing, which is prohibitive for many healthcare researchers
- No built-in survey methodology guidance or academic rigor checks for question construction
Jotform
Patient Satisfaction SurveyJotform offers the widest volume of healthcare form templates with HIPAA-friendly features and a strong no-code builder. Templates are basic starting points focused more on data collection than research-quality measurement.
What it does well
- Massive template library with 200+ healthcare surveys and forms for various use cases
- Free tier with HIPAA-friendly features available as an upgrade, making it accessible
- Strong form-building capabilities with conditional logic, e-signatures, and PDF generation
Where it falls short
- No AI-powered adaptive questioning—all forms are static with pre-defined paths
- Templates are basic form builders rather than methodologically sound research instruments
- No transparency into question design rationale or survey methodology validation
SurveySparrow
Patient Satisfaction Survey TemplateSurveySparrow differentiates with a conversational UI, sentiment analysis on open-ended responses, and HIPAA compliance. The word cloud analytics and anonymous feedback features are useful but remain surface-level compared to AI-driven probing.
What it does well
- Built-in sentiment analysis with word clouds for open-ended response analysis
- HIPAA-compliant platform with anonymous feedback collection capabilities
- Conversational UI with emojis, GIFs, and multimedia for higher engagement
Where it falls short
- No AI-powered follow-up questions—sentiment analysis is post-hoc, not interactive
- Word cloud analysis provides frequency data but not the deep contextual understanding AI interviews deliver
- No academic methodology validation or reproducibility features for research use
Qualtrics
Patient Experience SolutionQualtrics is the enterprise gold standard with HCAHPS-approved vendor status, real-time dashboards, and benchmarking across 500+ hospitals. However, it's priced for large health systems, and its AI analytics are 'black box' with no prompt or model transparency.
What it does well
- Official HCAHPS-approved vendor with built-in benchmarking across 500+ hospitals
- Expert-designed surveys validated by leading healthcare providers with role-based dashboards
- Comprehensive closed-loop follow-up systems and EMR integration via Health Connect
Where it falls short
- Enterprise pricing makes it completely inaccessible for academic researchers and small clinics
- AI analytics are black-box—no visibility into models, prompts, or logic for research reproducibility
- Implementation requires dedicated consultants, making setup time-intensive and expensive
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.