Free Patient Satisfaction Evaluation Sheet Template
Patient Satisfaction Evaluation Sheet
Patient Information
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Patient ID |
12345678 |
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Age |
45 |
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Gender |
Female |
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Date of Visit |
December 10, 2054 |
1. Overall Satisfaction
Please rate your overall satisfaction with the following aspects of your visit:
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Aspect |
Very Satisfied |
Satisfied |
Neutral |
Dissatisfied |
Very Dissatisfied |
|---|---|---|---|---|---|
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Overall experience with the healthcare facility |
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Overall experience with healthcare providers |
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2. Communication with Healthcare Providers
Rate the communication you experienced with your healthcare providers:
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Aspect |
Very Satisfied |
Satisfied |
Neutral |
Dissatisfied |
Very Dissatisfied |
|---|---|---|---|---|---|
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Clarity of information provided |
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Time spent with the healthcare provider |
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Provider’s ability to listen and address concerns |
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3. Facility and Environment
Please rate the following aspects of the healthcare facility:
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Aspect |
Very Satisfied |
Satisfied |
Neutral |
Dissatisfied |
Very Dissatisfied |
|---|---|---|---|---|---|
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Cleanliness and tidiness of the facility |
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Comfort and convenience of waiting areas |
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Accessibility and ease of location |
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4. Timeliness
Rate the following based on your experience:
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Aspect |
Very Satisfied |
Satisfied |
Neutral |
Dissatisfied |
Very Dissatisfied |
|---|---|---|---|---|---|
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Wait time for appointment |
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Wait time to be seen by the healthcare provider |
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5. Staff Interaction
Rate the following based on your experience:
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Aspect |
Very Satisfied |
Satisfied |
Neutral |
Dissatisfied |
Very Dissatisfied |
|---|---|---|---|---|---|
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Courtesy and professionalism of the staff |
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Responsiveness of the staff to your needs |
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6. Overall Rating
-
Would you recommend this facility to others?
| Yes | ☐ | No | ☐ |
Additional Comments:
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Comments |
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Thank you for completing this evaluation. Your feedback is valuable in helping us improve the quality of care we provide.
