This printable patient satisfaction survey helps clinics, practices, and outpatient departments collect honest feedback from every patient, including those who never open an email or patient portal. Its 14 questions print on one sheet, front and back, and take about five minutes to complete.
What this survey measures
The questions cover the full visit experience: the type of visit, how it was booked and who the patient saw, how easy it was to book, waiting time on the day, how well the provider listened and explained, staff courtesy, time with the provider, involvement in care decisions, whether the next steps were clear, and the state of the facilities. A likelihood-to-recommend question gives you a simple score to track over time, and an open comment box captures anything the fixed questions miss.
How to use it on paper
Hand the survey to patients at checkout or leave copies in the waiting room with a drop box at reception. Patients fill the checkboxes with a blue or black pen. Collect the completed forms and scan them in batches: PaperSurvey reads the checkbox answers with optical mark recognition and converts the handwritten comments to text automatically, so results appear in your dashboard without any manual data entry.
Customize this template
Add your practice logo, reword the statements to match your specialty, or add questions about specific departments. The paper layout reflows automatically as you edit, and every copy you print stays scannable.
Preview the PDF above, or use this template to start collecting patient feedback today.