Office Visit Survey example

This is an example Office Visit Survey survey. This survey includes questions like:

We hope this will help you create your own Office Visit Survey survey. We have not tested the validitiy or reliability of this survey. However, you may use this as a starting point to help your own survey instrument. Feel free to change and edit any of our survey templates to help you get started.

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1) What was the purpose of your visit to our office?
2) Did you have an appointment?
  • Yes
  • No
3) How long did you have to wait before you were seen by a representative?

Please tell us how satisfied or dissatisfied you were with each of the following:

4) How satisfied were you with the way you were treated by the staff at our office?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
5) How satisfied were you with the amount of time you had to wait before being seen by a representative?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
6) How satisfied were you with the way your questions were answered?
  • Very Satisfied
  • Somewhat Satisfied
  • Undecided
  • Somewhat Dissatisfied
  • Very Dissatisfied
7) How would you rate the courtesy you were shown by staff at our office?
  • Excellent
  • Good
  • Fair
  • Poor
  • Don't Know

Please tell us how much you agree or disagree with the following statements:

8) The staff were knowledgeable.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
9) The staff was friendly and courteous.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
10) My questions were answered fully.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
11) I was given complete attention by the office representative.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
12) My visit to the office was a pleasant experience.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
13) Overall, would you say your visit to our office was very positive, somewhat positive, somewhat negative or very negative?
  • Very Positive
  • Somewhat Positive
  • Undecided
  • Somewhat Negative
  • Very Negative
14) What, if anything, did you like most about your visit to our office?
15) What, if anything, did you like least about your visit to our office?
16) Please tell us what, if anything, we can do to make future visits to our office more enjoyable for you.
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