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Healthcare & Clinical

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
Q01
Message

Welcome and thank you for participating in this survey about your healthcare experiences. This survey explores how well your healthcare provider fits your needs and what matters most to you when choosing providers. It takes approximately 12 minutes to complete. Your participation is entirely voluntary, and you may stop at any time. There are no right or wrong answers — we are interested in your honest opinions. All responses are confidential and will be reported only in aggregate. By continuing, you consent to participate.

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: 17
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.

  1. Clinical expertise in my condition
  2. Communication style
  3. Cultural understanding
  4. Location or convenience
  5. Appointment availability
  6. Cost transparency
  7. 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: 17
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: 17
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: 17
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: 17
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: 17
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: 17
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

  • Includes a dedicated AI follow-up interview that adaptively probes patient–provider fit themes surfaced earlier in the survey, rather than stopping at fixed-choice questions
  • Combines quantitative opinion-scale ratings (listening, respect, involvement in decisions, scheduling ease) with a ranking exercise and open-text feedback to capture both the size and the reasons for mismatch
  • Captures structured mismatch drivers (communication, access, clinical fit) alongside demographic and payment/language context needed for equity-focused provider-matching analysis
  • Ends with an automated report generation step, so healthcare organizations or researchers get synthesized findings without manually coding open-ended responses

Jotform

600+ Healthcare Assessment Forms

This is a broad category/library page listing hundreds of generic healthcare assessment form templates rather than a single fielding-ready patient-provider fit survey. It's useful for finding intake, screening, or satisfaction forms quickly, but none appear purpose-built to isolate mismatch drivers across clinical, communication, and access dimensions. Customization is drag-and-drop form building rather than adaptive interviewing.

What it does well

  • Very large library of pre-built healthcare form templates covering many use cases
  • Familiar drag-and-drop form builder likely speeds up basic customization
  • Broad reach across many healthcare sub-topics (intake, consent, satisfaction, etc.)

Where it falls short

  • Static question sets with no adaptive AI follow-up probing into individual responses
  • No built-in voice AI interview or guided screen-share task option
  • As a general template hub, no template appears specifically structured around patient-provider fit, mismatch drivers, or care-preference ranking; users would need to build/customize substantially

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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