Emergency Room Visit example

This is an example Emergency Room Visit survey. This survey includes questions like:

We hope this will help you create your own Emergency Room Visit 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.

Sign up to start building your survey!

1) Are you male or female
2) What is your age?
3) Do you have health insurance?
4) Why did you visit the emergency room?
  • Injury or accident
  • Illness
  • Maternity care
  • Mental health
  • Other:
5) What services, other than seeing a physician, did you receive? (check all that apply)
  • X-rays
  • MRI/CAT Scan
  • EEG
  • Laboratory work
  • Other:
6) What procedures, if any, did you have?
  • Stitches
  • Wound care
  • Casting for broken bone
  • Breathing treatment
  • Other:
7) How long did you wait in the waiting area to be seen by ER staff?
8) How long did you wait in the examination room to be seen by an ER physician?
9) Please tell us what, if anything, we can do to improve the emergency room services of this hospital.
Sign up to start building your survey!