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 was knowledgeable.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
9) My questions were answered fully.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
10) I was given complete attention by the office representative.
  • Strongly Disagree
  • Disagree
  • Undecided
  • Agree
  • Strongly Agree
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