Q01
Message
All templatesHealthcare & Clinical
Patient Experience & Satisfaction Survey (NPS + CSAT)
Measures patient satisfaction across appointment scheduling, provider interaction quality, and health technology reliability using NPS and CSAT frameworks. Designed for clinics and health systems seeking actionable improvement data.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
24 questions · ~11 min
Q02
Multiple Choice
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
Q03
Multiple Choice
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
Q04
Message
The following questions ask about the clinician you saw during this visit. Please indicate your level of agreement with each statement.
Q05
Multiple Choice
Which of the following technologies, if any, 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
Q06
Opinion Scale
How likely are you to recommend this clinic or provider to a friend or family member?
Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q07
Multiple Choice
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 feedback is valuable and will be used to improve the quality of care and access at this clinic. If you have any questions or concerns, please contact [clinic contact information].
Q09
Multiple Choice
What type of visit was it?
- In-person visit
- Video/telehealth
- Phone consult
- Messaging/portal only
Q10
Opinion Scale
How easy was it to schedule your appointment?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q11
Opinion Scale
My clinician listened carefully to my concerns.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q12
Opinion Scale
Overall, how reliable was the technology you used during this visit?
Scale: 1 – 7
Min:Very unreliableMax:Very reliable
Q13
Long Text
Based on your responses in this survey, is there anything else you would like to share about your experience with access, provider interaction, or technology during this visit?
Q14
Multiple Choice
Which gender do you identify with?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q15
Dropdown
Which best describes the service you received?
- Primary care
- Specialist
- Urgent care
- Diagnostic/imaging
- Therapy/behavioral health
- Other
Q16
Multiple Choice
Approximately how long did you wait past your scheduled appointment time?
- No wait or not applicable
- 1–10 minutes
- 11–20 minutes
- 21–30 minutes
- 31–60 minutes
- More than 60 minutes
Q17
Opinion Scale
My clinician explained my condition and treatment options clearly.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q18
Long Text
If you experienced any technical issues during this visit, please briefly describe what happened.
Q19
AI Interview
We'd like to learn a bit more about your visit experience. An AI moderator will ask you a couple of brief follow-up questions based on your responses.
Q20
Dropdown
Approximately how many healthcare visits have you had in the past 12 months?
- 0 (this was my first)
- 1–2
- 3–5
- 6–10
- More than 10
- Prefer not to say
Q21
Long Text
If scheduling was difficult, what specifically made it hard?
Q22
Opinion Scale
My clinician treated me with courtesy and respect.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q23
Opinion Scale
My clinician spent enough time with me during the visit.
Scale: 1 – 7
Min:Strongly disagreeMax:Strongly agree
Q24
Rating Scale
Overall, how would you rate the quality of care you received during this visit?
Range: 1 – 5
Min:Very poorMax:Excellent
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
- Combines quantitative NPS/CSAT scoring with an AI follow-up interview that can probe deeper on scheduling difficulties, clinician interaction quality, or technology issues in the respondent's own words.
- Covers the full patient journey in one instrument — scheduling ease and wait time, clinician listening/clarity/courtesy/time spent, technology reliability, and overall NPS — rather than a single satisfaction snapshot.
- Open-text questions on scheduling friction and technical issues let patients explain root causes, which the adaptive AI interview can then follow up on for specifics.
- Transparent prompts and automated per-response quality scoring mean clinics get clean, analyzable data plus an auto-generated report without manual coding of open-ended responses.
QuestionPro
Health Insurance Satisfaction Survey TemplateA fielding-ready static template focused on health insurance/patient satisfaction rather than the full clinic visit journey. Good for quick deployment with standard question logic, but narrower in scope than a combined NPS+CSAT clinic experience survey. No mention of adaptive interviewing or voice-based data collection.
What it does well
- Ready-to-use template within an established survey platform
- Focused specifically on insurance/patient satisfaction context
- Likely supports standard skip logic and reporting dashboards
Where it falls short
- Static question set with no adaptive AI follow-up to probe individual responses
- No voice AI interview option or guided screen-share tasks
- No visible per-response quality scoring or transparent prompt methodology
SurveySparrow
Free Patient Satisfaction Survey Template | For Healthcare IndustryA free, fielding-ready patient satisfaction template built on SurveySparrow's conversational survey format, which gives it a friendlier feel than a plain form. It still relies on fixed question flows rather than true AI-driven adaptive questioning, and covers general healthcare satisfaction rather than a structured NPS+CSAT breakdown across scheduling, provider, and technology.
What it does well
- Conversational, chat-style survey UI that can feel more engaging than a traditional form
- Free to use, lowering the barrier for smaller clinics
- Purpose-built for the healthcare industry
Where it falls short
- No adaptive AI interview capability — question flow is fixed/branching, not dynamically generated per response
- No voice AI interview or guided screen-share task option
- No automated per-response quality scoring or transparent AI prompt disclosure
SurveyMonkey
Patient Satisfaction Survey TemplateA well-established, fielding-ready post-visit patient satisfaction template from a major survey platform, likely offering solid analytics and benchmarking. It is a static questionnaire format, and there's no indication it includes adaptive follow-up questioning, voice-based interviews, or automated qualitative analysis of open-ended responses.
What it does well
- Backed by a widely used, mature survey platform with strong analytics and benchmarking tools
- Specifically designed for post-visit patient feedback
- Likely offers customizable branding and distribution options
Where it falls short
- Static form structure with no adaptive AI probing on individual answers
- No voice AI interview or guided screen-share task option
- No automated per-response quality scoring or transparent prompt methodology for follow-up questions
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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