Q01
Message
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Medical Examination & Check-Up Experience Survey
Captures how patients experience scheduling, wait times, communication, and results delivery during routine or diagnostic medical exams. Includes a best-worst trade-off to prioritize service improvements and an AI follow-up interview that reconstructs what actually happened during the visit — especially around how results were explained — rather than just a satisfaction score.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~7 min
Q02
Multiple ChoiceRequired
Which best describes the exam or check-up you recently had?
- Annual physical / general check-up
- Specialist diagnostic exam (e.g., imaging, cardiac, women's/men's health)
- Preventive screening (e.g., blood work, cancer screening)
- Pre-employment or insurance-required exam
- Follow-up exam for an existing condition
- Other
Q03
Opinion ScaleRequired
How easy was it to schedule this appointment?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q04
Rating Scale
How would you rate the friendliness and helpfulness of the front-desk / check-in staff?
Range: 1 – 5
Min:PoorMax:Excellent
Q05
MatrixRequired
Thinking about the exam itself, how much do you agree with each statement?
5 rows × 5 columns
- The wait time before being seen was reasonable
- The exam felt thorough and unrushed
- The provider explained what they were doing and why
- The facility felt clean and well-organized
- My results were explained in a way I understood
Columns: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
Opinion ScaleRequired
How likely are you to recommend this clinic for a similar exam to a friend or family member?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q07
Best–Worst Trade-off (MaxDiff)
If the clinic could only improve a few things, which of these matter most to you, and which matter least?
- Shorter wait times
- Lower out-of-pocket cost
- Clearer explanation of results
- Friendlier staff
- Cleaner, more comfortable facility
- Easier online scheduling
- Faster follow-up after the visit
Pick best & worst per setBest:Matters mostWorst:Matters least
Q08
AI Interview
Reconstruct exactly what happened when the respondent's results were shared with them: who explained them, what was said, whether they understood next steps, and whether anything was left unclear or worrying. If they gave a low recommend score, probe for the single most negative moment of the visit and what would have fixed it in the moment; if high, probe what specifically stood out as exceptional.
Q09
Long Text
Is there anything else about your exam experience — good or bad — you'd like the clinic to know?
Q10
Multiple Choice
What is your age range? (optional)
- Under 25
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Q11
Multiple Choice
What is your gender? (optional)
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q12
Message
Thank you for sharing your experience! Your responses will be reviewed by the clinic's patient experience team to improve scheduling, communication, and overall care quality.
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
- Includes a best-worst (MaxDiff) trade-off question so clinics know which specific improvements (scheduling, wait times, communication, results delivery) to prioritize, rather than a flat satisfaction average.
- Uses an AI follow-up interview specifically to reconstruct what actually happened when the patient's results were shared — surfacing miscommunication or gaps in explanation that a scale question would miss.
- Combines a matrix of agreement statements about the exam itself with opinion-scale questions on scheduling ease and likelihood to recommend, giving both structured and open-ended signal in one flow.
- Closes with an open-ended long-text question and optional demographics, so qualitative detail and benchmarking data are captured without forcing every respondent to answer them.
QuestionPro
Medical Examination Services Survey TemplateA ready-to-field static survey template covering patient experience of medical examination services, built on QuestionPro's standard survey engine. It's directly comparable in topic and intent to our template, focused on patient-reported experience rather than clinical documentation. Customization relies on QuestionPro's usual question library rather than adaptive interviewing.
What it does well
- Fielding-ready template purpose-built for medical examination patient experience, not a generic form repurposed for this use case
- Backed by QuestionPro's broad survey feature set (logic, multiple question types, reporting dashboards)
- Likely easy to customize and deploy quickly for clinics already familiar with QuestionPro
Where it falls short
- Static question set with no adaptive AI follow-up to probe deeper into how results or diagnoses were actually communicated
- No indication of per-response automated quality scoring to flag low-effort or contradictory answers
- No published transparent methodology or prompt logic behind how questions are interpreted or scored
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.