When was your most recent visit with this clinic or provider?
- Within the last 7 days
- 1-4 weeks ago
- 1-3 months ago
- More than 3 months ago
- Not sure
What type of visit was it?
- In-person visit
- Video/telehealth
- Phone consult
- Messaging/portal only
Which best describes the service you used?
- Primary care
- Specialist
- Urgent care
- Diagnostic/imaging
- Therapy/behavioral health
- Other
How easy was it to schedule the appointment?
Range: 1 – 10
Min: Very difficultMid: NeutralMax: Very easy
About how many minutes did you wait past your scheduled time? If none or not applicable, enter 0.
Accepts a numeric value
Whole numbers only
How did you schedule or request this visit? Select all that apply.
- Phone call
- Online patient portal
- Clinic website
- Walk-in
- Referral from another provider
- Mobile app
- Other
If scheduling was difficult, what made it hard?
Max 600 chars
Thinking about the clinician you saw, how would you rate each?
| Rows | Very poor | Poor | Fair | Good | Excellent |
|---|
| Listened carefully to you | • | • | • | • | • |
| Explained your condition and options clearly | • | • | • | • | • |
| Showed respect and courtesy | • | • | • | • | • |
| Involved you in decisions | • | • | • | • | • |
| Spent enough time with you | • | • | • | • | • |
Overall, how would you rate the care you received?
Scale: 10 (star)
Min: Very poorMax: Excellent
Which technologies were part of this visit? Select all that apply.
- None
- Telehealth video
- Patient portal/app (forms, messages)
- Remote monitoring device
- Kiosk or check-in tablet
- Automated phone/SMS reminders
- Other
Please rate the reliability or quality of any technology used. If not used, select Not applicable.
| Rows | Very poor | Poor | Fair | Good | Excellent | Not applicable |
|---|
| Video connection quality | • | • | • | • | • | • |
| Audio clarity | • | • | • | • | • | • |
| Portal/app reliability | • | • | • | • | • | • |
| Text/email reminder accuracy | • | • | • | • | • | • |
| Check-in kiosk/tablet functionality | • | • | • | • | • | • |
Briefly describe any technical issues you experienced (if any).
Max 600 chars
How likely are you to recommend this clinic/provider to a friend or family member?
Range: 1 – 10
Min: Not at all likelyMid: NeutralMax: Extremely likely
Attention check: To confirm you’re paying attention, please select “Agree.”
- Strongly disagree
- Disagree
- Agree
- Strongly agree
- Prefer not to answer
What is your age?
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
Which gender do you identify with?
- Woman
- Man
- Non-binary
- Prefer not to say
Where do you live?
- United States
- Canada
- United Kingdom
- Australia
- India
- European Union (other)
- Other
What is the highest level of education you have completed?
- Less than high school
- High school or equivalent
- Some college or technical training
- Bachelor’s degree
- Graduate or professional degree
- Prefer not to say
What is your current employment status?
- Full-time
- Part-time
- Self-employed
- Unemployed and seeking work
- Not working by choice (e.g., student, caregiver, retired)
- Unable to work
- Prefer not to say
About how many healthcare visits have you had in the past 12 months?
Accepts a numeric value
Whole numbers only
Welcome! This brief survey takes about 5 minutes. Your responses are confidential and used for quality improvement.
Anything else you’d like to share about access, bedside manner, or technology during this visit?
Max 600 chars
AI Interview: 2 Follow-up Questions on your visit
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast Thank you for your time—your feedback helps improve care and access.