Patient Satisfaction Survey Template

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Patient Satisfaction Survey Template (English)

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[INSERT NAME OF HOSPITAL/CLINIC]

[INSERT YOUR HOSPITAL/CLINIC ADDRESS]

[INSERT YOUR HOSPITAL/CLINIC CONTACT NUMBER/S]

 PATIENT SATISFACTION SURVEY

Dear Patient:

We at [INSERT NAME OF YOUR HOSPITAL/CLINIC] aim to live up to our commitment of giving the best medical treatment and healthcare services to our patients. We are interested in knowing your thoughts about the services we provide here at [INSERT NAME OF YOUR HOSPITAL/CLINIC]. 

Take a few minutes of your time and answer this survey. The information you share will help us in evaluating and improving the services we offer. We thank you for sharing your experience with us.

The [INSERT NAME OF HOSPITAL/CLINIC] team

Date of your appointment:                                         Age: 

Name of Doctor:                                                              Gender:        F         M

How long have you been visiting the office of the doctor at [INSERT NAME OF YOUR HOSPITAL/CLINIC]?

• Less than two times

• Two to Four times

• Five to Seven times

• More than Seven times

Are you using a healthcare plan in availing the medical and healthcare services of [INSERT NAME OF YOUR HOSPITAL/CLINIC]? If no, skip next question and continue onto the question after.

• Yes

• No

What is the name of your healthcare plan? 

Are you employed?       Yes          No

If yes, Employer’s Name: 

If no, what is your source of income?

What is your educational attainment?

          Elementary Grad           Secondary Grad           College Grad           Post-Graduate Degree

            Others, please specify: 

Please encircle your rating of the following statements relevant to the medical/healthcare services you have experienced and the doctors you have visited at [INSERT NAME OF YOUR HOSPITAL/CLINIC].

	About the Hospital/Clinic Medical and Healthcare Services:	Very Dissatisfying	Fairly Dissatisfying	Satisfying	Fairly Satisfying	Very Satisfying	Not Applicable
1	I am satisfied with the person I spoke with when I called the hospital/clinic to inquire about the medical and healthcare services they provide.	1	2	3	4	5	N/A
2	I had ease in scheduling checkups and medical or healthcare procedures.	1	2	3	4	5	N/A
3	There is cleanliness in the amenities I have utilized when I was admitted at the hospital/clinic.	1	2	3	4	5	N/A
4	I had no problem in the check-in process of the hospital/clinic.	1	2	3	4	5	N/A
5	The assisting nurses gave clear and sufficient instructions relevant to the procedure as well as what to expect before the proceeding with the medical procedure.	1	2	3	4	5	N/A
6	All the attending nurses and physicians of the hospital/clinic were observing courtesy and care to each patient.	1	2	3	4	5	N/A
7	Despite the complicated procedure, I felt assured and comfortable within the procedure room.	1	2	3	4	5	N/A
8	The hospital/clinic provide useful information about the medical and healthcare procedures they offer through different kinds of medium within the premises of the facility.	1	2	3	4	5	N/A
9	The doctors and the nurses have exceptional teamwork in responding to and in executing various medical and healthcare procedures.	1	2	3	4	5	N/A
10	I am assured of the quality of medical or healthcare service the hospital/clinic provides.	1	2	3	4	5	N/A
	About the Doctor/Nurse/Staff:	Very Dissatisfying	Fairly Dissatisfying	Satisfying	Fairly Satisfying	Very Satisfying	Not Applicable
11	I can easily contact my doctor even after the hospital/clinic hours particularly for emergency reasons.	1	2	3	4	5	N/A
12	There is comfort even while waiting in the doctor’s office.	1	2	3	4	5	N/A
13	The doctor/staff/nurse is easily approachable when i have concerns.	1	2	3	4	5	N/A
14	Follow-up and care information like test results and medicines is obtained without so much difficulty.	1	2	3	4	5	N/A
15	Instructions on how to improve the condition of your health is relayed by your doctor in a caring and a professional way.	1	2	3	4	5	N/A
		Very Dissatisfying	Fairly Dissatisfying	Satisfying	Fairly Satisfying	Very Satisfying	Not Applicable
16	Overall medical attention from your doctor as well as the staff and nurses in assistance.	1	2	3	4	5	N/A
17	Overall rating of the medical and healthcare services provided at the hospital/clinic.	1	2	3	4	5	N/A
18	I am satisfied with the medical procedure/healthcare service I have experience when i visited the hospital/clinic.	1	2	3	4	5	N/A
19	Overall experience at [INSERT NAME OF YOUR HOSPITAL/CLINIC	1	2	3	4	5	N/A
20	The hospital/clinic is a facility i can rely on for the improvement of my health condition.	1	2	3	4	5	N/A

Would you recommend your doctor to your family, relatives, and friends when it concerns health?

• Highly Likely

• Somewhat Likely

• Likely

• Somewhat Unlikely

• Highly Unlikely

Would you recommend [INSERT NAME OF YOUR HOSPITAL/CLINIC] to your family, relatives, and friends when it concerns health?

• Highly Likely

• Somewhat Likely

• Likely

• Somewhat Unlikely

• Highly Unlikely

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