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Patient Visit Experience & Care Feedback Survey

Captures how patients experienced a recent visit — wait times, communication, staff respect, and overall likelihood to recommend — with a best-worst prioritization of improvement areas and an AI follow-up that digs into the specific moment behind their recommendation score. Built for clinics, hospitals, and practice managers tracking care quality.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

12 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to share feedback on your recent visit. Your honest answers help our care team improve — this should take about 4-5 minutes, and your responses are kept confidential.

Q02
Opinion ScaleRequired

How likely are you to recommend this clinic to family or friends?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q03
MatrixRequired

Thinking about your most recent visit, how would you rate each of the following?

5 rows × 5 columns
  • Time spent waiting
  • Clarity of explanations from your care team
  • Friendliness and respect from staff
  • Cleanliness of the facility
  • Ease of scheduling your visit
Columns: Poor · Fair · Good · Very good · Excellent
Q04
Multiple ChoiceRequired

At your last visit, how long did you wait past your scheduled appointment time before being seen?

  • Seen early or on time
  • 1-15 minutes
  • 16-30 minutes
  • 31-60 minutes
  • More than an hour
Q05
Multiple ChoiceRequired

Did you feel you had enough time to ask questions during your visit?

  • Yes, completely
  • Somewhat
  • Not really
  • No, not at all
Q06
AI Interview

Reconstruct the specific moment that shaped the respondent's recommendation score: what happened, who was involved, and whether it was about wait time, communication, or something else. Anchor on whichever matrix item they rated lowest and ask them to walk through what occurred step by step. If the score was high, probe what specifically stood out so it can be reinforced elsewhere in the practice.

Q07
Multiple Choice

Which best describes the main reason for your visit?

  • Routine checkup or physical
  • New symptom or concern
  • Follow-up on an existing condition
  • Procedure or surgery
  • Test results or lab review
Q08
Best–Worst Trade-off (MaxDiff)Required

If our clinic could only improve two of these, which would matter most and least to your experience?

  • Shorter wait times
  • More time with your provider
  • Clearer explanation of diagnosis or treatment
  • Better communication between visits
  • Friendlier front-desk staff
  • Easier online scheduling
  • More comfortable waiting area
  • Faster follow-up after the visit
Pick best & worst per setBest:Most important to improveWorst:Least important to improve
Q09
Long Text

Is there anything else about your visit — good or bad — you'd like us to know?

Q10
Multiple Choice

What is your age range?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75+
  • Prefer not to say
Q11
Multiple Choice

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q12
Message

Thank you for sharing your feedback! Your responses go directly to our care quality team and help us fix real issues in scheduling, communication, and care delivery.

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

  • Goes beyond satisfaction ratings with an AI follow-up interview that reconstructs the specific moment behind each patient's recommendation score, surfacing root causes static forms miss
  • Uses a best-worst (max-diff) prioritization exercise so clinics know exactly which improvement areas matter most versus least, not just averaged ratings
  • Combines a quantitative core (recommendation score, matrix ratings on wait time/communication/respect) with an open-ended long-text question and screening questions like visit reason and time waited, giving both breadth and depth
  • Automated per-response quality scoring and an auto-generated report mean practice managers get analysis-ready output instead of raw spreadsheet data to sort through manually

Jotform

Create Free Patient Feedback Forms - Patient Feedback Form Templates

This is a template gallery/category page offering multiple static patient feedback form layouts rather than a single fielding-ready survey. It's built for quick deployment and easy customization via Jotform's drag-and-drop builder, useful for clinics wanting a fast, no-frills intake of feedback.

What it does well

  • Wide selection of pre-built form layouts to choose from
  • Familiar drag-and-drop form builder for quick customization
  • Likely supports embedding on clinic websites or kiosks

Where it falls short

  • Static form fields only — no adaptive follow-up questioning to probe why a patient rated something poorly
  • No mention of automated per-response quality scoring or auto-generated analysis reports
  • No transparent methodology for how responses are interpreted or prioritized

Typeform

Patient Feedback Form Template

A single conversational-style template focused on collecting patient feedback with Typeform's signature one-question-at-a-time UX. It's designed for a pleasant respondent experience but relies on fixed question paths rather than dynamic follow-up.

What it does well

  • Polished, conversational one-question-at-a-time interface likely improves completion rates
  • Easy to customize branding and question wording
  • Simple to deploy via link or embed

Where it falls short

  • No adaptive AI interviewing — logic branching is rule-based, not a dynamic conversational probe into a specific visit moment
  • No built-in best-worst prioritization exercise for improvement areas
  • No automated quality scoring or auto-generated insights report

SurveyMonkey

Patient Satisfaction Survey Template

A dedicated post-visit patient satisfaction template covering standard experience metrics, positioned similarly to our use case. It benefits from SurveyMonkey's established analytics and benchmarking tools, but the question set appears fixed rather than adaptive.

What it does well

  • Purpose-built for post-visit satisfaction tracking, directly comparable in scope
  • Backed by SurveyMonkey's broader analytics dashboards and benchmarking data
  • Likely offers straightforward multi-channel distribution (email, link, embed)

Where it falls short

  • No adaptive AI follow-up to dig into the specific moment behind a low or high recommendation score
  • No max-diff-style prioritization built into the template as described
  • No transparent per-response quality scoring mechanism mentioned

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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