Healthcare Patient Experience Survey
Patient Information
Name
Email
Age
Gender
Female
Male
Other
Prefer not to say
Experience with Healthcare Facility
How would you rate your overall experience?
1
2
3
4
5
Was it easy to schedule your appointment?
Yes
No
How would you rate the cleanliness of the facility?
1
2
3
4
5
How long did you have to wait before being attended to?
Less than 15 minutes
15-30 minutes
30-60 minutes
More than 1 hour
Staff Interaction
Did you feel respected by the staff?
Yes
No
How well did staff explain your treatment and answer questions?
Poor
Fair
Good
Very Good
Excellent
Feedback & Suggestions
What can we improve?
Additional Comments