Patient Experience Survey
Track patient satisfaction across appointments and care quality.
12 questions · 4 pages · about 4 minutes to answer · fully editable after you start
Patient experience is measured everywhere and acted on rarely, usually because the survey asks about satisfaction in general rather than about the parts of a visit a clinic can change. This template asks about the specific stages: getting an appointment, the wait, whether the clinician listened, explained things understandably, left time for questions and involved the patient in decisions, and whether the patient left knowing what happens next. A short grid covers the practical side — reception, cleanliness, the waiting area and privacy — with a Not applicable choice.
That question about what happens next matters more than its length suggests. Patients who leave unclear about the next step are the ones who miss follow-ups, call back with avoidable questions, and report poor experiences for reasons unrelated to their clinical care. An overall rating and the standard recommend question sit alongside two open questions, and an optional last page asks age group and whether the patient needed any support to attend or communicate.
Health responses are sensitive by definition. The intro tells patients their answers will not affect their care and asks them not to include medical details. Consider a consent notice explaining what you will do with the answers, and a retention window so responses are deleted automatically once you have acted on them — both are per-survey settings, and both are the kind of thing a patient is entitled to ask about.
Template preview
This is a picture of every question as a respondent would see it, so nothing on it can be clicked or typed into. Use this template to get your own editable copy.
Opens in the Light theme, or in your own default theme if you have set one — change it anytime to any of the 4 built-in looks, or build your own on a paid plan.
Page 1 of 4
About your visit
This survey is about your most recent visit to our clinic. It takes about 4 minutes. It is anonymous: your name, email address and IP address are not recorded with your answers, so they cannot affect your care. Please do not include personal medical details.
Q1.What kind of visit was it?
- A routine appointment or check-up
- An appointment about a new problem
- A follow-up appointment
- A test, scan or procedure
- Other…
Q2.How easy was it to get an appointment?*
- Very difficult
- Fairly difficult
- Neither easy nor difficult
- Fairly easy
- Very easy
- I did not book an appointment
Q3.How long did you wait past your appointment time?
- I was seen on time or early
- Up to 15 minutes
- 16 to 30 minutes
- More than 30 minutes
- I cannot remember
Page 2 of 4
Your care
Q4.Thinking about the clinician you saw, how much do you agree with each statement?*
| Strongly disagree | Disagree | Neither agree nor disagree | Agree | Strongly agree | Not applicable | |
|---|---|---|---|---|---|---|
| They listened to me carefully | ||||||
| They explained things in a way I could understand | ||||||
| I had enough time to ask my questions | ||||||
| They involved me in decisions about my care as much as I wanted | ||||||
| They treated me with dignity and respect |
Q5.How would you rate each of the following?
| Poor | Fair | Good | Excellent | Not applicable | |
|---|---|---|---|---|---|
| Reception and front-desk staff | |||||
| Cleanliness of the clinic | |||||
| Comfort of the waiting area | |||||
| Privacy during your visit |
Q6.When you left, did you know what happens next?*
- Yes, completely
- Yes, to some extent
- No
- Nothing further was needed
Q7.Overall, how would you rate the care you received?
Q8.How likely are you to recommend this clinic to friends or family if they needed similar care?
Page 3 of 4
In your own words
Q9.What was good about your visit?
Q10.How could we improve your next visit?
Page 4 of 4
About you (optional)
Q11.What is your age group?
- Under 18
- 18 to 34
- 35 to 54
- 55 to 74
- 75 or over
- Prefer not to say
Q12.Did you need any support to attend or to communicate during your visit, such as an interpreter or access help?
- No
- Yes, and I received it
- Yes, but I did not receive it
- Prefer not to say
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