Q01
Message
All templatesIndustry-Specific
Patient Visit Experience Survey (CAHPS-Aligned)
Measures how a patient experienced a specific provider visit — getting the appointment, provider communication, staff courtesy, and an overall rating — modeled on the CAHPS Clinician & Group Visit 2.0 survey used across medical practices and health systems. An AI follow-up interview digs into the exact moment or interaction that drove the patient's overall rating, turning a single number into an actionable story.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple Choice
Was this the first time you saw this particular provider?
- Yes, first visit
- No, I've seen this provider before
Q03
Multiple ChoiceRequired
How many days passed between when you first tried to schedule this appointment and the day you were actually seen?
- Same day
- 1-3 days
- 4-7 days
- 1-2 weeks
- More than 2 weeks
Q04
MatrixRequired
Thinking about this visit, how often did your provider do each of the following?
5 rows × 4 columns
- Explained things in a way you could understand
- Listened carefully to you
- Seemed to know important information about your medical history
- Showed respect for what you had to say
- Spent enough time with you
Columns: Never · Sometimes · Usually · Always
Q05
Multiple ChoiceRequired
Thinking about the front-desk and office staff during this visit, how often were they courteous and helpful to you?
- Never
- Sometimes
- Usually
- Always
Q06
Opinion ScaleRequired
Using a 0-10 scale, how would you rate this provider overall?
Scale: 0 – 10
Min:Worst provider possibleMax:Best provider possible
Q07
Multiple ChoiceRequired
How likely are you to recommend this provider to friends and family?
- Definitely not
- Probably not
- Probably yes
- Definitely yes
Q08
AI Interview
Probe why the respondent gave the overall rating they did: ask them to describe the specific moment or interaction during this visit that most shaped that score. If the rating was high, find out what exactly stood out as exceptional and worth protecting; if it was middling or low, identify the single biggest fix that would raise it and whether it traces back to the provider's communication, the wait, or the staff. Anchor every follow-up on concrete details from this specific visit rather than general impressions of the practice.
Q09
Multiple Choice
In general, how would you rate your overall health?
- Excellent
- Very good
- Good
- Fair
- Poor
- Prefer not to say
Q10
Multiple Choice
Which age range do you fall into?
- 18-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65-74
- 75 or older
- Prefer not to say
Q11
Multiple Choice
How do you describe your gender?
- Man
- Woman
- Non-binary
- Prefer not to say
Q12
Dropdown
What is the highest level of education you have completed?
- Less than high school
- High school graduate
- Some college
- Bachelor's degree
- Graduate or professional degree
- Prefer not to say
Q13
Message
Thank you for sharing your experience! Your responses feed directly into this practice's patient experience reports and help guide improvements to scheduling, communication, and staff training.
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
- Uses the same core structure as the CAHPS Clinician & Group visit survey — appointment access, provider communication, staff courtesy, and an overall 0-10 rating — so results are benchmarkable against a recognized standard
- Pairs the overall rating with an AI follow-up interview that asks the patient to describe the exact moment or interaction that drove their score, turning a number into a specific, actionable story
- Includes a matrix question on specific provider communication behaviors and a separate staff-courtesy question, so low scores can be traced to the front desk or the clinician
- Collects standard case-mix variables (general health, age range, gender, education) so results can be segmented and fairly compared across patient groups
SurveyMonkey
Patient Satisfaction Survey TemplateA ready-to-field, static patient satisfaction survey covering visit basics and satisfaction ratings. It's a solid general-purpose template but is not explicitly modeled on the CAHPS visit survey structure and doesn't publish its underlying question methodology.
What it does well
- Fielding-ready template usable immediately without custom build-out
- Backed by SurveyMonkey's broad distribution, panel, and analytics infrastructure
- Familiar, easy-to-deploy survey format for healthcare practices
Where it falls short
- Fixed question set with no adaptive follow-up to probe why a patient gave a particular rating
- No voice-based interview option for patients who prefer speaking over typing
- No automated per-response quality scoring or transparent prompt/methodology disclosure
SurveySparrow
Doctor Visit Form TemplateA conversational-style form template for capturing doctor visit details, benefiting from SurveySparrow's chat-like UI. It reads as a general visit form rather than a CAHPS-aligned experience survey, and there's no indication it drills into the reasoning behind a patient's overall rating.
What it does well
- Chat-style interface that can feel more conversational than a traditional form
- Fielding-ready template for quick deployment
- Mobile-friendly design typical of SurveySparrow's product
Where it falls short
- Conversational UI is scripted, not adaptive — it can't generate a genuine follow-up question based on a specific answer
- No voice AI interview option for patients
- No mechanism to automatically score response quality or surface the exact moment driving a low or high rating
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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