Patient experience questionnaire (peq) questions in this example
1. What was the date of your visit?
The answer should be a date/time input:
- *
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:
- Poor
- Fair
- Good
- Very good
- Excellent
4. Did your healthcare provider listen to your concerns and answer your questions?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- 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:
- Not at all
- Somewhat
- Moderately
- Mostly
- 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:
- Not at all
- Somewhat
- Moderately
- Mostly
- 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:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
8. Was it easy to schedule an appointment?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
9. Were you seen by your healthcare provider within a reasonable amount of time?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- 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:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
11. Was the facility clean and comfortable?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
12. Did your healthcare provider coordinate with other healthcare professionals involved in your care?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
13. Were you provided with clear instructions on how to manage your condition at home?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
14. Were you provided with referrals to other healthcare professionals or resources as needed?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
15. Were you given an opportunity to provide feedback on your experience with the healthcare organization?
The answer should be a single choice:
- Not at all
- Somewhat
- Moderately
- Mostly
- Completely
16. Overall, how would you rate your experience with the healthcare organization?
The answer should be a single choice:
- Very poor
- Poor
- Fair
- Good
- Very good
- Excellent
17. Would you recommend the healthcare organization to others?
The answer should be a single choice:
- Definitely not
- Probably not
- Not sure
- Probably
- Definitely
18. Do you have any suggestions for how the healthcare organization could improve its services?
The answer should be a multi line text input.