Post-Visit Patient Satisfaction Template
1.
On a scale of 0 to 10,
How likely is it that you would recommend your provider to a friend or family member?
0 for Not at all likely, 10 for Extremely likely
Not at all likely
Extremely likely
0
1
2
3
4
5
6
7
8
9
10
2.
Overall, how satisfied or dissatisfied were you with your last visit to our office?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
3.
How easy or difficult was it to schedule your appointment at a time that was convenient for you?
Very easy
Somewhat easy
Neither easy nor difficult
Somewhat difficult
Very difficult
4.
How convenient was the appointment time you were able to get?
Extremely convenient
Very convenient
Somewhat convenient
Not so convenient
Not at all convenient
5.
In your opinion, how convenient is the location of our office?
Extremely convenient
Very convenient
Somewhat convenient
Not so convenient
Not at all convenient
6.
How comfortable was the lobby and waiting area?
Extremely comfortable
Very comfortable
Somewhat comfortable
Not so comfortable
Not at all comfortable
7.
Did your appointment with your provider start early, late or on time?
Very early
Somewhat early
On time
Somewhat late
Very late
8.
Overall, how would you rate the care you received from your provider?
Excellent
Very good
Good
Fair
Poor
9.
How well did your provider listen to your needs?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
10.
How well did your provider answer your questions?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
11.
How well did your provider explain your treatment options?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
12.
How well did your provider explain your follow-up care?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
13.
Is there anything we could have done to improve your last visit?