Patient Experience Questionnaire (PEQ) Template

1. What was the date of your visit?

The answer should be a date/time input:

1. *

2. What was the reason for your visit?

The answer should be a multi line text input.

3. How would you rate the clarity of the communication you received from your healthcare provider?

The answer should be a single choice:

1. Poor
2. Fair
3. Good
4. Very good
5. Excellent

4. Did your healthcare provider listen to your concerns and answer your questions?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

5. Did your healthcare provider explain your diagnosis and treatment options in a way that was easy to understand?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

6. Were you provided with adequate information about your medications, including their purpose and potential side effects?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

7. Did you feel that you had enough time to discuss your concerns with your healthcare provider?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

8. Was it easy to schedule an appointment?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

9. Were you seen by your healthcare provider within a reasonable amount of time?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

10. Were you provided with clear instructions on how to prepare for your appointment (e.g., fasting requirements, medication restrictions)?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

11. Was the facility clean and comfortable?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

12. Did your healthcare provider coordinate with other healthcare professionals involved in your care?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

13. Were you provided with clear instructions on how to manage your condition at home?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

14. Were you provided with referrals to other healthcare professionals or resources as needed?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

15. Were you given an opportunity to provide feedback on your experience with the healthcare organisation?

The answer should be a single choice:

1. Not at all
2. Somewhat
3. Moderately
4. Mostly
5. Completely

16. Overall, how would you rate your experience with the healthcare organisation?

The answer should be a single choice:

1. Very poor
2. Poor
3. Fair
4. Good
5. Very good
6. Excellent

17. Would you recommend the healthcare organisation to others?

The answer should be a single choice:

1. Definitely not
2. Probably not
3. Not sure
4. Probably
5. Definitely

18. Do you have any suggestions for how the healthcare organisation could improve its services?

The answer should be a multi line text input.