Q01
Message
All templatesHealthcare & Clinical
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~7 min
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 TemplatesThis 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 TemplateA 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 TemplateA 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
Frequently asked questions
What questions are in the “Patient Visit Experience & Care Feedback Survey” template?
The template includes 12 ready-to-use questions, starting with: “Thanks for taking a few minutes to share feedback on your recent visit. Your honest answers help our care team improve —…” · “How likely are you to recommend this clinic to family or friends?” · “Thinking about your most recent visit, how would you rate each of the following?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 12 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
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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