Q01
Message
All templatesHealthcare & Clinical
Patient Waiting List Experience Survey
Captures how patients experience the wait between referral and treatment — expectations vs. reality, communication quality, anxiety, and health impact — for clinics and health systems managing waiting lists. An AI follow-up interview digs into the specific moment communication broke down or worked well, surfacing fixes that satisfaction scores alone can't show.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
What type of appointment or procedure were you waiting for?
- Specialist consultation
- Diagnostic test or scan
- Surgery or procedure
- Follow-up appointment
- Other
Q03
NumberRequired
Roughly how many weeks passed between your referral and your appointment or procedure?
Q04
Opinion ScaleRequired
Compared to what you were originally told, how did the actual wait feel?
Scale: 1 – 5
Min:Much longer than expectedMax:Much shorter than expected
Q05
MatrixRequired
Thinking about how the clinic communicated with you during the wait, how would you rate each of the following?
4 rows × 5 columns
- Being told how long the wait would likely be
- Receiving updates while you waited
- How easy it was to reach someone with questions
- Being told what to do if your condition changed
Columns: Poor · Fair · Good · Very good · Excellent
Q06
Opinion ScaleRequired
How anxious or stressed did the waiting period make you feel?
Scale: 1 – 7
Min:Not at all anxiousMax:Extremely anxious
Q07
Multiple ChoiceRequired
While you were waiting, did your condition change?
- Got worse
- Stayed about the same
- Improved
- Not sure
Q08
Multiple Choice
During the wait, did you seek care elsewhere (for example, an emergency room, urgent care, or a private provider)?
- No, I waited it out
- Yes, once
- Yes, more than once
Q09
Rating ScaleRequired
Overall, how satisfied were you with your experience on the waiting list, from referral to being seen?
Range: 1 – 5
Min:Very dissatisfiedMax:Very satisfied
Q10
AI Interview
Explore the specific moment during the wait that most shaped the respondent's overall satisfaction rating — ask them to walk through what happened, what they expected versus what occurred, and how the clinic communicated (or didn't) at that point. If they reported worsening symptoms or seeking outside care, probe what would have prevented that and whether they felt anyone was tracking their case. If satisfaction was high, identify exactly what communication or reassurance made the difference so it can be replicated.
Q11
Multiple Choice
What is your age range?
- Under 18
- 18-29
- 30-44
- 45-59
- 60-74
- 75 or older
- Prefer not to say
Q12
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q13
Message
Thank you for sharing your experience. Your responses will be combined with other patients' feedback to help our team shorten waits and improve communication for people currently on the list.
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 a satisfaction score with a matrix question rating communication quality across multiple dimensions and an opinion-scale item comparing expected vs. actual wait, so you see where the gap actually opened up
- Includes an AI follow-up interview that probes the specific moment during the wait that most shaped the patient's overall experience, surfacing concrete fixes rather than just a number
- Captures downstream impact often missed by simple wait-time forms: anxiety/stress level, whether the condition changed, and whether the patient sought care elsewhere (e.g., ER/urgent care) while waiting
- Full patient journey covered end-to-end — referral timing, communication quality, emotional impact, outcome-related behavior, overall satisfaction, and demographics — in one fieldable, auto-reported survey
Jotform
Patient Waiting List Form TemplateThis is a drag-and-drop form for logging patients onto a waiting list (contact info, appointment type) rather than a survey exploring how the wait felt to them. It's fielding-ready for intake/logistics, but not built to capture expectation gaps, anxiety, or communication quality. Best suited to list management, not experience research.
What it does well
- Easy drag-and-drop customization and clinic branding
- Wide range of integrations (payment, calendar, CRM) common to Jotform's ecosystem
- Simple to embed on a clinic or health system website
Where it falls short
- Static field-based form with no adaptive follow-up questioning into why or how communication broke down
- No built-in scoring of response quality or automated interpretive reporting
- No voice AI interview option for patients who prefer speaking over typing
SurveySparrow
Free Patient Waiting List Form TemplateSurveySparrow's version is also framed as a waiting list intake form with a conversational, chat-like UI, rather than a deep-dive experience survey. It's ready to field for collecting waitlist entries, but the template as titled doesn't appear designed to probe anxiety, communication breakdowns, or downstream care-seeking behavior. Positioned more for list intake than experience insight.
What it does well
- Conversational, mobile-friendly form format that can feel less clinical to fill out
- Supports multi-channel distribution (web, email, link sharing)
- Easy branching for basic form logic
Where it falls short
- No adaptive AI interviewing to dig into the specific moment a patient's experience turned positive or negative
- No transparent, inspectable AI prompt or automated per-response quality scoring
- Lacks structured measurement of expectation-vs-reality gaps or health impact during the wait
Frequently asked questions
What questions are in the “Patient Waiting List Experience Survey” template?
The template includes 13 ready-to-use questions, starting with: “Thanks for taking a few minutes to share your experience while waiting for care. Your answers help us reduce stress and…” · “What type of appointment or procedure were you waiting for?” · “Roughly how many weeks passed between your referral and your appointment or procedure?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 13 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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