Patient satisfaction survey template

Patient Satisfaction Survey

Date: Date

Your feedback helps us improve. Please rate from 1 (poor) to 5 (excellent).

Visit details

| Item | Details |

| --- | --- |

| Visit Date | Visit Date |

| Clinic or Department | Clinic or Department |

| Visit Type | Visit Type: clinic / emergency / inpatient |

Ratings

| No. | Item | Rating out of 5 |

| --- | --- | --- |

| 1 | Item 1 | Rating out of 5 1 |

| 2 | Item 2 | Rating out of 5 2 |

| 3 | Item 3 | Rating out of 5 3 |

| 4 | Item 4 | Rating out of 5 4 |

| 5 | Item 5 | Rating out of 5 5 |

| 6 | Item 6 | Rating out of 5 6 |

| 7 | Item 7 | Rating out of 5 7 |

| 8 | Item 8 | Rating out of 5 8 |

Your views

| Item | Details |

| --- | --- |

| What you liked most | What you liked most |

| What needs improving | What needs improving |

| Would you recommend us | Would you recommend us: yes / no |

Name (optional): Name (optional)

Mobile (optional): Mobile (optional)