Patient satisfaction survey questionnaire is primarily intended to gauge how well a patient is satisfied by the services he or she receives in a health facility.  The health facilities use the answers given by the respondents to improve the quality of services given. In addition, the data collected during the survey is used to track the quality of service improvement put together by the health facilities over time. Health facilities can also use the same to gauge their performance against the same in other similar facilities. Federal funded health facilities have a more standardized survey form provided for their use by the government.


Patient Satisfaction Survey Form

Age: ________________________________

Gender: _________________


Pacific____________ Asian__________ American______________

Indian  Islander__________White African American_______Hispanic/ Latino ______

Other (specify) ___________

Rate the following services using numbers 1-5 with;

5 (great),


3 (ok),

2(fair) and;

1 (poor).

Q1. The ease of accessing medical care in our health facility _________________

Q2. Ability of accessing a qualified medic _________________

Q3. Hour of operation in the health facility _________________

Q4. Convenience of the health facility’s location _________________

Q5. Prompt answering of calls __________

Q6. Time you spend in the facility’s waiting room _________________

Q7. Time spent in the exam room _________________

Q8. The time spent waiting for tests to be conducted _________________

Q9. Time spent waiting for your test results _________________

Q10. The medical provider’s services _________________

Q11. The staff’s willingness to help you _________________

Q12. The neatness and cleanliness of our facility _________________

Q13. Our means of payment _________________

Q14. State any suggestions you may have for our facility’s improvement _________________________________________________________

Thank you for participating in our survey!