Healthcare Patient Satisfaction

Healthcare Patient Satisfaction — Form Fields

This surveys template includes 14 fields. Collect patient satisfaction data on appointment scheduling, provider communication, facility cleanliness, and overall care quality. Free to customize and use on ZenBuild.

• Type of Visit (dropdown selection, required) — options: Routine check-up, Follow-up visit, Specialist consultation, Urgent / Walk-in, Procedure / Surgery, Telehealth / Virtual
• Date of Visit (text, required)
• Ease of scheduling an appointment (rating, required) — 1 = Very difficult, 5 = Very easy
• Wait time at the office (rating, required) — 1 = Unacceptable, 5 = Minimal wait
• Friendliness and helpfulness of front desk staff (rating, required)
• Provider listened to my concerns (rating, required)
• Provider explained my diagnosis and treatment clearly (rating, required)
• Cleanliness and comfort of the facility (rating, required)
• Overall quality of care received (rating, required)
• Were your questions answered to your satisfaction? (multiple choice, required) — options: Yes, completely, Partially, No
• Would you recommend this practice to others? (multiple choice, required) — options: Definitely, Probably, Probably not, Definitely not
• What did we do well? (long text, optional)
• How could we improve your experience? (long text, optional)
• Email (optional) (email, optional) — If you'd like us to follow up on your feedback