Patient Feedback Form for Hospitals & Clinics (Free)
Free patient feedback form format for hospitals and clinics in English, Hindi and Tamil: 12 questions, a 3-question WhatsApp version and a score sheet.
By Radiatus team · Published 04 Nov 2026 · Updated 04 Nov 2026 · 9 min read
What questions should a patient feedback form ask?
A patient feedback form should ask one question for each step of the visit the patient actually experienced, on the same rating scale, plus one open question about what to improve. Rating each step separately tells you where to act; a single "overall satisfaction" score does not. Pick from this question bank by touchpoint:
| Touchpoint | Example questions (rate 1–5) |
|---|---|
| Booking and registration | It was easy to get an appointment · The front desk was polite and helpful · Registration was quick |
| Waiting | My waiting time was reasonable · I was told how long I would wait · The waiting area was comfortable |
| Doctor | The doctor listened to me · The doctor explained my condition and treatment clearly · I had enough time with the doctor |
| Lab and diagnostics | Sample collection was comfortable · Reports were ready when promised |
| Pharmacy | Medicines were available · I understood how to take my medicines |
| Billing | Charges were explained before treatment · The bill was clear |
| Cleanliness and facilities | The clinic was clean · Toilets and drinking water were clean |
| Overall | I would recommend this clinic to family and friends |
Keep the form to about 12 questions so it takes two minutes. Do not ask for diagnosis or personal health details on a feedback form; a name and phone number should be optional, so patients can answer honestly.
Free patient feedback form format (English)
Copy this format for a printed form at the reception desk. Patients tick one box per row: 1 = very poor, 2 = poor, 3 = average, 4 = good, 5 = excellent.
| # | Question | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|---|
| 1 | It was easy to get an appointment | ☐ | ☐ | ☐ | ☐ | ☐ |
| 2 | The front desk staff were polite and helpful | ☐ | ☐ | ☐ | ☐ | ☐ |
| 3 | Registration was quick | ☐ | ☐ | ☐ | ☐ | ☐ |
| 4 | My waiting time was reasonable | ☐ | ☐ | ☐ | ☐ | ☐ |
| 5 | The doctor listened to me carefully | ☐ | ☐ | ☐ | ☐ | ☐ |
| 6 | The doctor explained my treatment clearly | ☐ | ☐ | ☐ | ☐ | ☐ |
| 7 | Nurses and lab staff were caring | ☐ | ☐ | ☐ | ☐ | ☐ |
| 8 | Reports were ready when promised | ☐ | ☐ | ☐ | ☐ | ☐ |
| 9 | Medicines were available and explained | ☐ | ☐ | ☐ | ☐ | ☐ |
| 10 | Charges were explained and the bill was clear | ☐ | ☐ | ☐ | ☐ | ☐ |
| 11 | The clinic was clean | ☐ | ☐ | ☐ | ☐ | ☐ |
| 12 | I would recommend this clinic to others | ☐ | ☐ | ☐ | ☐ | ☐ |
Add below the table: "What should we improve?" with three ruled lines, then optional name, phone and date, and "May we call you about your feedback? Yes / No".
Patient feedback form in Hindi and Tamil
Patients answer more honestly in the language they think in. Use the same twelve questions so you can combine the scores across languages.
Hindi (रोगी प्रतिक्रिया फ़ॉर्म) — 1 = बहुत खराब, 5 = बहुत अच्छा
| # | प्रश्न | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|---|
| 1 | अपॉइंटमेंट लेना आसान था | ☐ | ☐ | ☐ | ☐ | ☐ |
| 2 | रिसेप्शन स्टाफ़ विनम्र और मददगार था | ☐ | ☐ | ☐ | ☐ | ☐ |
| 3 | पंजीकरण जल्दी हुआ | ☐ | ☐ | ☐ | ☐ | ☐ |
| 4 | प्रतीक्षा का समय उचित था | ☐ | ☐ | ☐ | ☐ | ☐ |
| 5 | डॉक्टर ने मेरी बात ध्यान से सुनी | ☐ | ☐ | ☐ | ☐ | ☐ |
| 6 | डॉक्टर ने इलाज साफ़-साफ़ समझाया | ☐ | ☐ | ☐ | ☐ | ☐ |
| 7 | नर्स और लैब स्टाफ़ ने अच्छी देखभाल की | ☐ | ☐ | ☐ | ☐ | ☐ |
| 8 | रिपोर्ट समय पर मिली | ☐ | ☐ | ☐ | ☐ | ☐ |
| 9 | दवाइयाँ उपलब्ध थीं और समझाई गईं | ☐ | ☐ | ☐ | ☐ | ☐ |
| 10 | शुल्क पहले बताया गया और बिल स्पष्ट था | ☐ | ☐ | ☐ | ☐ | ☐ |
| 11 | क्लिनिक साफ़-सुथरा था | ☐ | ☐ | ☐ | ☐ | ☐ |
| 12 | मैं इस क्लिनिक की सिफ़ारिश दूसरों से करूँगा/करूँगी | ☐ | ☐ | ☐ | ☐ | ☐ |
अंत में: "हमें क्या सुधारना चाहिए?"
Tamil (நோயாளர் கருத்துப் படிவம்) — 1 = மிக மோசம், 5 = மிகச் சிறப்பு
| # | கேள்வி | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|---|
| 1 | சந்திப்பு நேரம் பெறுவது எளிதாக இருந்தது | ☐ | ☐ | ☐ | ☐ | ☐ |
| 2 | வரவேற்பு ஊழியர்கள் மரியாதையாகவும் உதவியாகவும் இருந்தனர் | ☐ | ☐ | ☐ | ☐ | ☐ |
| 3 | பதிவு விரைவாக முடிந்தது | ☐ | ☐ | ☐ | ☐ | ☐ |
| 4 | காத்திருப்பு நேரம் நியாயமாக இருந்தது | ☐ | ☐ | ☐ | ☐ | ☐ |
| 5 | மருத்துவர் என் பிரச்சினையைக் கவனமாகக் கேட்டார் | ☐ | ☐ | ☐ | ☐ | ☐ |
| 6 | மருத்துவர் சிகிச்சையைத் தெளிவாக விளக்கினார் | ☐ | ☐ | ☐ | ☐ | ☐ |
| 7 | செவிலியர்களும் ஆய்வக ஊழியர்களும் அக்கறையுடன் கவனித்தனர் | ☐ | ☐ | ☐ | ☐ | ☐ |
| 8 | அறிக்கைகள் சொன்ன நேரத்தில் கிடைத்தன | ☐ | ☐ | ☐ | ☐ | ☐ |
| 9 | மருந்துகள் கிடைத்தன, விளக்கப்பட்டன | ☐ | ☐ | ☐ | ☐ | ☐ |
| 10 | கட்டணம் முன்பே சொல்லப்பட்டது, பில் தெளிவாக இருந்தது | ☐ | ☐ | ☐ | ☐ | ☐ |
| 11 | கிளினிக் சுத்தமாக இருந்தது | ☐ | ☐ | ☐ | ☐ | ☐ |
| 12 | இந்த கிளினிக்கை மற்றவர்களுக்குப் பரிந்துரைப்பேன் | ☐ | ☐ | ☐ | ☐ | ☐ |
இறுதியில்: "நாங்கள் எதை மேம்படுத்த வேண்டும்?"
A 3-question version for WhatsApp after the visit
Long forms do not work on WhatsApp. Send three questions a few hours after the visit, while it is fresh:
Thank you for visiting [Clinic name] today. 1. How was your visit overall? Reply 1 to 5 (5 = excellent). 2. Was your waiting time reasonable? Reply YES or NO. 3. What one thing should we improve?
Ask the open question last, and only once. After the patient answers, whatever the rating, you may share your Google review link (see below). In Appointment Reminder App, completed visits can trigger a WhatsApp feedback request automatically on the Growth plan, with ratings and comments collected in one report; see the feature list and our appointment message templates for wording in other languages.
Paper, QR code or WhatsApp: which collects more honest feedback?
Each channel has strengths, and many clinics use two. We do not quote response rates, because they depend on your patients and how you ask; compare what each method is good at:
| Paper at the desk | QR code at the desk | WhatsApp after the visit | |
|---|---|---|---|
| Who answers | Patients waiting with a pen | Patients with a smartphone, while still in the clinic | Patients at home, after the visit |
| Honesty | Lower when staff watch | Better, on their own phone | Often the most candid, away from the clinic |
| Effort for staff | Typing results into a sheet | None; answers are stored | None when automated |
| Older patients | Easiest | Harder | Easy if they use WhatsApp |
| Languages | Print each version | Labels switch per patient | Message in the patient's language |
How do you score feedback and act on it?
Score each question separately, every month. Two measures are enough:
- Average score per question = sum of ratings ÷ number of answers.
- Top-2-box share = answers rated 4 or 5 ÷ all answers × 100. This common survey measure shows how many patients were clearly satisfied, and is easier to explain to staff than an average.
Illustrative example (made-up numbers to show the method): in one month, 40 patients answer question 4, "My waiting time was reasonable". The ratings are 2 × 1, 6 × 2, 10 × 3, 14 × 4 and 8 × 5. The sum is 2 + 12 + 30 + 56 + 40 = 140, so the average is 140 ÷ 40 = 3.5. Twenty-two patients gave 4 or 5, so the top-2-box share is 22 ÷ 40 = 55 %.
| Question | Answers | Average | Top-2-box | Action |
|---|---|---|---|---|
| 4. Waiting time | 40 | 3.5 | 55 % | Lowest: run a one-day waiting-time audit |
| 6. Doctor explained clearly | 40 | 4.4 | 88 % | Keep doing this |
| 10. Bill was clear | 38 | 3.9 | 68 % | Show prices before treatment |
All figures in the table are illustrative. Fix the lowest-scoring question first, tell staff what you changed and compare next month's score. Read every comment; one specific complaint is often more useful than a score.
How do you ask for Google reviews the right way?
Ask for a Google review only after the patient has given feedback, and ask everyone the same way. Google's policies prohibit offering incentives such as discounts or free tests in exchange for reviews, and prohibit asking only happy patients in a way that filters out critical ones. A simple, honest line works: "Thank you for your feedback. If you have a minute, a Google review helps other patients find us: [link]." Reply to every review, positive or negative, politely and without sharing any medical details.
How many feedback forms are enough, and how often?
Collect feedback continuously, but review it on a fixed rhythm: weekly for comments and complaints, monthly for scores. A small clinic seeing 30 to 40 patients a day does not need every patient to answer; a steady trickle of forms from every day of the week and every doctor is more useful than a burst in one week. Avoid two common biases:
- Only the friendly patients get the form. If the receptionist hands forms to patients who seem happy, the scores look better than reality. Offer the form, the QR code or the WhatsApp question to every patient in the same way.
- Only one shift is covered. Evening patients often meet different staff and longer waits. Make sure forms come from every session, and compare morning and evening scores separately once you have enough answers.
When a question has only a handful of answers in a month, treat the score as a hint, not a verdict, and read the comments instead.
What should you do when feedback contains a complaint?
A complaint on a feedback form is a chance to keep a patient who would otherwise leave quietly. Close the loop within a day or two:
- Acknowledge: if the patient left a phone number and agreed to be contacted, call or message to thank them and say what you will look into. Do not argue on the first call.
- Check the facts: look at the appointment, the waiting time and who was on duty. A token queue report or appointment log helps here.
- Fix the cause: a rude remark needs a word with the staff member; a long wait may need a change to slot lengths or a second counter.
- Tell the patient: a short message saying what you changed shows the feedback mattered.
- Record it: keep a simple complaints log with date, issue, action and outcome, and review it monthly with the team.
Never discuss a patient's medical details in a public reply or on social media, even if the patient did. Move the conversation to a phone call.
Should different departments use different forms?
Use one core form for every patient so scores are comparable, and add two or three department questions where they matter. A diagnostic lab might add "Sample collection was comfortable" and "I received my report on WhatsApp when promised". A dental clinic might add "Pain was managed well during treatment". A physiotherapy clinic might ask "My exercises were explained so I can do them at home". Keep the core twelve questions unchanged from month to month; changing the wording resets your comparison.
Make it digital
Appointment Reminder App includes a patient feedback questionnaire (desk QR) template in its forms builder: patients scan a QR code at reception and answer on their phone, with Tamil and Hindi labels on the Growth and Scale plans, and every answer is stored and exportable as CSV for your score sheet. Start from the patient forms page, which also offers a free registration form. After the visit, automatic WhatsApp feedback requests with your Google review link run on the Growth plan alongside WhatsApp appointment reminders. Plans start at ₹2,999 a month plus GST; see pricing, or set up the desk QR form from the forms builder during the 14-day free trial.
Questions people ask
What is a patient feedback form?
A patient feedback form asks patients to rate each step of their visit, such as registration, waiting time, the doctor, lab, pharmacy, billing and cleanliness, usually on a 1–5 scale, plus one open question. Appointment Reminder App offers it as a desk QR form and as WhatsApp feedback after the visit.
What questions should be in a hospital feedback form?
Ask one question per touchpoint the patient used: ease of booking, front desk courtesy, registration speed, waiting time, the doctor listening and explaining, nursing and lab care, reports on time, medicines, billing clarity, cleanliness and whether they would recommend you. Appointment Reminder App's template covers the core five.
Is there a patient feedback form in Hindi?
Yes. This guide includes the full 12-question form in Hindi and Tamil alongside English, with the same questions so scores combine across languages. In Appointment Reminder App the desk QR feedback form shows Hindi or Tamil labels with English below on the Growth and Scale plans.
How do you calculate patient satisfaction from feedback forms?
For each question, calculate the average rating and the top-2-box share, the percentage of answers rated 4 or 5, every month, then act on the lowest-scoring question first. Appointment Reminder App exports form answers to CSV, so the calculation takes minutes in any spreadsheet.
Should I collect feedback on paper or online?
Use paper for older patients who prefer it and a QR code or WhatsApp for everyone else; patients are often more candid on their own phone, away from staff. Appointment Reminder App supports a desk QR form on every plan and automatic WhatsApp feedback requests on Growth.
Can I ask patients for a Google review after feedback?
Yes, if you ask everyone the same way and offer nothing in return; Google prohibits incentivised reviews. Ask after the patient has given feedback, with a simple link. Appointment Reminder App offers your Google review link after the feedback step and records who opened it.
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