How to Create a Simple Patient Feedback Form

Developing patient feedback forms involves picking the right questions that dig deep into the patient's experience, while still being easy to fill out and submit.

When this feedback is used wisely, it can transform patient care by creating a powerful loop: listen – learn – improve.

Let’s see how clinics use patient feedback forms, which questions to include, and how to efficiently distribute them to patients. We will also throw in some examples to help you create your own forms.

What is a patient feedback form?

A patient feedback form is a questionnaire designed to collect insights and opinions regarding a patient’s overall experience with the clinic. Its primary purpose is to measure patient satisfaction and gather actionable data for improving service quality and patient care. 

The forms themselves can vary in format — digital surveys, paper questionnaires, interactive online platforms — but the aim is to capture the patient's voice in a structured and consistent format.

The timing of sending out these forms is just as crucial as the questions they contain — ideally, at a point when the patient's experience is fresh in their mind, yet allowing enough time for them to have processed their visit. In our experience, the ideal time is 24 to 48 hours after the visit.

While patient feedback forms can serve a variety of purposes, here are the most common use cases:

• Quality improvement: To help identify strengths and weaknesses in patient care. Providers can pinpoint areas for improvement, from waiting room comfort to the clarity of communication.
• Measuring patient satisfaction: Patient feedback forms can be a great way to measure both the satisfaction with a specific service as well as the overall patient experience.
• Asking about specific services and facility environment: You can create and send targeted surveys that focus on specific services or the physical environment. This helps you make more informed decisions about service changes or capital projects.
• Monitoring patient outcomes: To track changes in patient outcomes over time, attributing improvements or declines to specific interventions or care models. Such long-term feedback is essential for evaluating the effectiveness of treatments and patient care strategies.

How to structure your patient questionnaire? 

An effective patient feedback form should assess different aspects of patient care and experience without asking for irrelevant details. 

While they are not mandatory, we recommend including the following elements:

• Demographic information: Name and contact info (if the survey isn’t anonymous), gender, date 
• Instructions on how to fill out the form: Begin with short, clear, and concise instructions on how to complete the questionnaire. If it is a really simple survey, you can skip this.
• The questions themselves: The exact questions you will include will depend on what you want to measure and get feedback on. Regardless, the questions should be formulated in a way that is easy to understand and answer.
• A ‘thank you’ message: You can conclude with a message that expresses gratitude for the patient’s time and insights. We also like to include conditional logic where patients who expressed high levels of satisfaction get politely asked to leave a review as well. 

Which questions to include in a simple patient feedback form?

When it comes to the questions in the form, here are some good all-rounders to use in your patient questionnaires:

1. How satisfied were you with the care you received? — Gauges overall satisfaction, providing a snapshot of the patient's experience.
2. Was the staff friendly and helpful? — Assesses the patient's interaction with staff, which is crucial for a positive healthcare experience.
3. Did you feel listened to and respected by your healthcare provider? — Evaluates the quality of communication and respect, foundational aspects of patient care.
4. How would you rate our facility? — Offers insights into the facility’s environment, which can impact patient comfort and perception of care.
5. Was your appointment time convenient for you? — Helps understand if the scheduling meets patient needs and preferences.
6. How likely are you to recommend our services to others? — Measures Net Promoters Score (NPS) and can also serve as an indicator of patient loyalty.
7. Do you have any suggestions for how we can improve? — An open-ended question where patients can share specific feedback in their own words.

The goal is to include questions that are direct and to the point. Most of the questions will be on a 1-5 Likert scale (very dissatisfied to very satisfied; strongly disagree to strongly agree). Learn more about using the right scales in your surveys here.

Often, the form will end with an open ended question where the patient can leave complaints, praises, or suggestions for improvement. You can add a few more of those, but be aware that the completion rate is typically lower for longer surveys.

How to distribute these forms to patients and get answers

Distributing patient feedback forms effectively involves different strategies for paper and digital formats. 

For paper forms, ensure they are readily available in waiting rooms or at checkout desks. Staff should encourage patients to complete these forms and instruct where to leave them after they’re done.

Digital forms usually have higher response and completion rates as they are more scalable and convenient. You can distribute them via email, text messages (SMS, Viber, WhatsApp…), or through patient portals. Digital formats also allow for quicker data analysis and response to negative feedback.

To ensure a high completion rate: 

• Write clear, straightforward questions and avoid medical jargon.
• Use consistent scales when measuring satisfaction.
• Find the right length; too long, and patients may not complete it, too short, and it may not provide enough insight. 
• Use minimalistic design to help maintain the patient's attention. Feel free to include your logo and brand colors for personalization.
• If it’s a digital survey, make sure it is user-friendly (back button to view and/or correct previous question, progress bar, categorizing questions into groups for longer surveys, etc.).

For more detailed design and writing tips, check out our guide on creating effective patient satisfaction surveys. 

Create and send patient questionnaires with InsiderCX

InsiderCX is a patient experience platform that helps clinics automate feedback collection and quality control.

The process is very simple. We help you design a survey based on your goals. The platform automates the whole collection process and automatically generates reports which you can use to measure satisfaction and find quality gaps.

Our mobile surveys average over 20% response rate and over 80% completion rate, helping healthcare providers get 7 to 10 times more responses. 

Still not convinced? Schedule a quick product demo or read our customer success stories.

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