Medical facility evaluation questionnaire template

Dear Sir or Madam,

By filling out this survey, you help us improve the patient/visitor experience and increase quality of provided services.

We truly appreciate your insight and your time.

Important: This survey is completely anonymous.

1. What was the reason for your visit?

Select one answer

  • Medical treatment
  • Visiting another patient

2. When was your last visit to [name of your medical facility]?

Select one answer

  • Today
  • Few days ago
  • Few weeks ago
  • More than one month ago

3. How did you select our facility?

Select one answer

  • Recommendation from my doctor
  • My own choice
  • Came through the emergency

4. What is your overall satisfaction with [name of your medical facility]?

(1 star = minimum satisfaction / 5 stars = maximum satisfaction)

5. How would you rate the individual aspects of our facility?

Select one answer in each row

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Cleanliness

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Comfort

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Privacy

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Safety

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Room amenities

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

Food services

  • Excellent
  • Good
  • Fair
  • Poor
  • Can't tell

6. How much do you agree with the following statements?

Select one answer in each row

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The facility creates a welcoming and calm environment.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The facility's infrastructure ensures easy accessibility and hassle-free parking.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The facility uses state-of-the-art medical equipment.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The facility canteen offers a wide selection of food and beverages.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

Waiting rooms and public areas offer a sufficient amount of seating and space.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

Visiting hours at this facility suit my needs well.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

The facility's information system provides clear and useful information.

  • Definitely agree
  • Rather agree
  • Rather disagree
  • Definitely disagree
  • Can't tell

7. How easy was it for you to find your way around the facility?

Select one answer

  • Choose...
    • Choose...
    • Very easy
    • Rather easy
    • Rather difficult
    • Very difficult

8. What other services would you like to see our facility offer?

Select one answer in each row

  • Definitely welcome
  • Not necessary
  • I don't care

A bookstore

  • Definitely welcome
  • Not necessary
  • I don't care

An internet kiosk

  • Definitely welcome
  • Not necessary
  • I don't care

A smart device charging station

  • Definitely welcome
  • Not necessary
  • I don't care

Children's playroom

  • Definitely welcome
  • Not necessary
  • I don't care

Physical and wellness therapy

  • Definitely welcome
  • Not necessary
  • I don't care

A prayer room

  • Definitely welcome
  • Not necessary
  • I don't care

9. How likely are you to recommend [name of your medical facility] to your friends and relatives?

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

Not at all likely

Extremely likely

10. Do you have any other suggestions for improving our services?

500

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Survey Templates Healthcare

Medical facility evaluation survey

Popularity 706 ×

Gather patient feedback with the medical facility evaluation questionnaire template. Get an objective assessment of your institution, staff and healthcare services.

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The survey sample is ideal for

  • hospital management,
  • directors of private medical centers and clinics.

Become a widely recognized hospital that is the most sought after. Use the data obtained from the answers to the medical facility evaluation questionnaire and focus on the most frequently mentioned areas. Patients usually evaluate the personnel composition of given department and the approach of individual members, material provision, quality of food, waiting time for specific examinations or administrative processes. Add questions to topics that are relevant to you in the survey sample.

Find out how you and your institution can benefit from the use of medical facility evaluation surveys.

The questionnaire template can be fully edited. Survio will process your answers into well-arranged tables and graphs.

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