patient satisfaction survey form

July 15, 2011

A patient satisfaction survey form is a great way to get a feedback from the various people who visit the various health care facilities to improve their physical well being. It is a great way of finding out the loopholes in this industry and hence improve their health care programs.

Sample patient satisfaction survey form:


Q1) Is this your first visit at this health care facility?

Q2) What is your date of birth? (Mm/dd/yyyy)

Q3) How long had you been kept waiting after your appointment time with your doctor?

Q4) After being taken to the exam room, how long after did your doctor arrive?

Q5) Were the hospital staff friendly and polite?

Q6) Were the lab technician staff and the radiology staff helpful?

Q7) Your experience with the health care provider on the day of your visit?

Q8) Were you satisfied with the advice you had received?

Q9) Was he able to treat you successfully for your existing medical condition?

Q10) Will you recommend our service to your friend?


Download patient satisfaction survey form in Word Format

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