Healthcare survey templates
Collect intake, screening, and patient feedback with clear, approachable forms.
- Healthcare
Patient Intake (General)
Light intake form for non-clinical info — name, contact, reason for visit.
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Patient Satisfaction
Post-visit CSAT — staff, wait time, recommend.
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Wellbeing Pulse
Anonymous wellbeing self-report — mood, sleep, support. Not a diagnostic tool.
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Telehealth Feedback
Virtual visit experience — tech, clinician, outcome.
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Appointment Booking Feedback
Booking flow only — easy, fast, accessible.
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Pharmacy Feedback
Post-pickup pharmacy CSAT.
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Discharge Feedback
Post-discharge feedback on understanding, follow-up, support.
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Provider Quality
Anonymous feedback on a specific provider — listening, clarity, respect.
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Insurance Experience
How members feel about claims, coverage, and support.
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General Wellness Check (Self-report)
Optional, non-clinical self-report — energy, sleep, exercise, stress.
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Dental Visit Check-out
Two-minute post-visit pulse for dental practices — for general satisfaction, not PHI / not HIPAA-compliant.
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Therapy Session Check-in
A gentle post-session pulse for mental-health providers — engagement, not clinical assessment. Not for PHI / not HIPAA-compliant.
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Pediatric Visit Intake
Caregiver-facing pre-visit intake for a child's appointment — basic context only, not for PHI / not HIPAA-compliant.
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PT Session Pulse
Per-session pain and adherence pulse for physical / sports therapy clinics — feedback only, not for PHI / not HIPAA-compliant.
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ER Visit Follow-up
Sent 24-48 hours after an ER discharge — short experience and clarity check. For satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Post-Surgery Follow-up
Two-week recovery and care-quality check after a planned surgery — for satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Lab / Imaging Visit
60-second CSAT for lab and imaging centers — wait, comfort, signage. Satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Caregiver Wellbeing Pulse
Wellbeing check for family caregivers — surfaces burnout signals. Engagement feedback only, not for PHI / not HIPAA-compliant.
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Family Feedback (Inpatient)
Feedback survey for family members of an inpatient — separate from patient CSAT. Satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Clinician Wellbeing Pulse
Anonymous burnout / wellbeing pulse for physicians, nurses, and allied staff — internal engagement feedback only, not for PHI / not HIPAA-compliant.
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Nurse Shift Pulse
60-second post-shift pulse for nursing staff — high-frequency operational signal, not for PHI / not HIPAA-compliant.
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Telehealth Follow-up
Outcome-oriented follow-up sent 48 hours after a telehealth appointment, distinct from the v1 Telehealth Feedback CSAT. Satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Prescription Fulfillment Check
Short check on whether a prescribed medication was filled and started — closes the prescribed-to-taking gap. Satisfaction feedback only, not for PHI / not HIPAA-compliant.
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Workplace Wellness Program Pulse
Pulse for an employer-sponsored wellness program (yoga, gym, EAP, etc.) — measures whether benefits land. Engagement feedback only, not for PHI / not HIPAA-compliant.
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