--- generated_by: surveylegend-page-markdown title: Patient Participation Survey | SurveyLegend description: Review how adults took part in a healthcare conversation. Seven optional questions cover asking questions, understanding options, and sharing preferences. canonical: https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/patient-engagement-template/ --- # Patient Participation Survey Template This patient participation survey helps care teams understand whether adults could ask questions, discuss preferences and follow the explanation of next steps during one appointment. Its seven optional questions focus on the conversation rather than an overall satisfaction rating. [Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/patient-engagement-template/#try-template) Preview on a device Show the desktop survey layout Show the tablet survey layout Show the mobile survey layout ![](https://www.surveylegend.com/survey-template-media/demo-backgrounds/patient-engagement-template-background.avif) **SurveyLegend** 1 / 7 Patient Participation Survey Before the conversation, did you have questions you wanted to ask? Yes, and I had them in mind or written down Yes, but I had not organized them No +2 more answer choices Next → Patient Participation Survey [Preview](https://www.surveylegend.com/survey-examples-templates/healthcare-and-hospital-surveys/patient-engagement-template/#try-template) Share [Facebook ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fpatient-engagement-template%2F)[LinkedIn ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fpatient-engagement-template%2F)[X ](https://x.com/intent/tweet?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fpatient-engagement-template%2F\&text=Patient%20Participation%20Survey%20Template)[Reddit](https://www.reddit.com/submit?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fhealthcare-and-hospital-surveys%2Fpatient-engagement-template%2F\&title=Patient%20Participation%20Survey%20Template) This patient participation survey helps care teams understand whether adults could ask questions, discuss preferences and follow the explanation of next steps during one appointment. Its seven optional questions focus on the conversation rather than an overall satisfaction rating. A patient can be satisfied with a visit yet leave a question unasked. Review what made participation easier or harder, including whether a decision was part of that appointment. Build the questionnaire in SurveyLegend after adapting the introduction to the service and its real feedback process. ## When to Use This Template Use this focused review when improving how a team involves patients in conversations. It complements broader [patient satisfaction ](https://www.surveylegend.com/research/patient-satisfaction-survey/)feedback by asking about opportunities to participate. Responses describe the patient's experience; they do not establish treatment quality or medical outcomes. **Create your patient participation survey in SurveyLegend** A patient can be satisfied with a visit yet leave a question unasked. Review what made participation easier or harder, including whether a decision was part of that appointment. ## 7 Patient Participation Survey Questions Think about your most recent scheduled conversation with this care team. All seven questions are optional. Do not include names, diagnoses, treatment details or other private medical information. This example is not monitored by a care team; use the service's normal contact route for a care question. Try the survey ## A little feedback. A clearer picture. Explore this 7-question example at your own pace. Every question is optional. Preview on a device Show the survey at full desktop width Resize the survey to a tablet-width preview Resize the survey to a mobile preview with scrolling inside the frame Choose a look Use Classic: a white survey card over the background photo Use Light: dark text over a light tint covering the background photo Use Dark: light text over a dark tint covering the background photo SurveyLegend demo Question 1 of 7 ### Patient Participation Survey 01 Before the conversation, did you have questions you wanted to ask? Choose one answer, or skip this question. Yes, and I had them in mind or written down Yes, but I had not organized them No I do not remember Prefer not to answer 02 How much opportunity did you have to ask the questions you wanted to ask? Choose one answer, or skip this question. Enough opportunity for all of them Enough for some of them Too little opportunity to ask any I did not have questions to ask Not sure Prefer not to answer 03 If options for a decision were discussed, how clear was the explanation? Choose one answer, or skip this question. Very clear Somewhat clear Neither clear nor unclear Somewhat unclear Very unclear No options were discussed I did not need to make a decision Prefer not to answer 04 How much opportunity did you have to explain what mattered to you? Choose one answer, or skip this question. As much as I wanted Some, but less than I wanted None, although I wanted to I did not want to discuss preferences Not sure Prefer not to answer 05 How clear was what would happen next after the conversation? Choose one answer, or skip this question. Very clear Somewhat clear Neither clear nor unclear Somewhat unclear Very unclear No next step was needed Prefer not to answer 06 What most limited your participation? Choose one answer, or skip this question. Not enough time Unfamiliar language or terms Difficulty knowing what to ask Communication or accessibility needs Feeling uncomfortable speaking up Being interrupted Nothing limited my participation Another factor Prefer not to answer 07 What could the team change to make a future conversation easier to take part in? Share your answer, or skip this question. #### One last look Review your answers before submitting this demo. 0 answered #### Thank you for trying the survey! You’ve tried the template from the respondent’s side. Make it your own with SurveyLegend. [Create your own survey](https://www.surveylegend.com/register/) Checking submission availability… This is a demo. We count starts and submissions only. Your answers stay in your browser and are never sent or saved. **—**Starts **—**Submissions Activity is temporarily unavailable. ## How to Adapt the Questionnaire Name the service and the conversation being reviewed. Keep 'no decision' and 'no questions' choices; participation should not be treated as a test patients must pass. Provide a clear alternative contact route for care concerns and explain who will read feedback. Follow SurveyLegend’s guidance on [sensitive questions ](https://www.surveylegend.com/survey-questions/sensitive-survey-questions/)when writing the privacy introduction, and do not promise anonymity solely because names are omitted. ## When to Ask Invite feedback soon after the conversation, when the patient has time and privacy to respond. Do not ask them to complete it in front of the clinician if that would make speaking honestly harder. Keep the invitation separate from care instructions and urgent contact information. ## How to Use the Responses Review opportunity to ask questions separately from whether questions existed. For option clarity, exclude 'no options' and 'no decision' from rating summaries and show their counts separately. Compare limited participation with the barrier selected, then use comments to choose a communication change to test. This questionnaire has no validated engagement score; do not sum the answer positions or use them to rank patients. ## What the Research Adds Roe and colleagues (2021) compared a 35-question prompt list with three generic prompts in a trial of 126 hand-clinic patients. The abstract reports that the longer list did not improve perceived involvement compared with the three prompts. Its stated outcome was “perceived involvement in care.” Read the [patient question-prompt trial ](https://stanfordhealthcare.org/publications/808/808992.html). This supports evaluating the experience of participation rather than assuming a longer question list is better. This SurveyLegend feedback questionnaire is not the trial’s validated outcome scale. ## Frequently asked questions ### Is this the Patient Activation Measure? No. It is an original feedback questionnaire about one conversation. It does not reproduce a validated activation instrument or generate a clinical score. ### What if no treatment decision was discussed? Keep the option stating that no decision was needed. Do not turn it into a negative rating. ### Can patients use it to ask for medical help? This feedback version is not a care-request channel. Show the provider's actual contact route separately and explain that the public example is not monitored by a care team. ## Printable Patient Participation Survey Offer the same seven fields on paper after the appointment, with readable options and space for the final comment. State where to return it and who reviews it. Keep care instructions and medical-contact routes separate from the feedback questionnaire. Paper responses need separate review or manual entry; they are not automatically added to online results. ![First page of the printable Patient Participation Survey Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/patient-engagement-template-pdf-preview.avif) [![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/patient-participation-survey-template.pdf) Export Patient Participation Survey as PDF ## AI Prompt: Patient Participation Survey Copy this patient participation survey prompt into an AI assistant to prepare the questionnaire. Review the result, then build and customize it in SurveyLegend. It does not automatically create or transfer a survey. ## Patient Participation Survey Prompt AI Prompt: Patient Participation Survey [Create this survey in SurveyLegend](https://www.surveylegend.com/register/) Copy the prompt into an AI assistant to draft the questions, then build your survey in SurveyLegend. [Sign in](https://app.surveylegend.com/) to SurveyLegend to build your patient participation survey Healthcare and Hospital Survey Templates 1. [![Preview of the Healthcare CAHPS® Visit Survey 2.0 Survey Template](https://www.surveylegend.com/survey-template-media/previews/template-healthcare-cahps-visit-survey-template-survey-preview.avif) Healthcare CAHPS® Visit v2.0 Survey Template Healthcare When a patient chooses to enter your hospital, the quality of the treatment they are going to receive is the most important thing. To reach a high quality in the treatment, several aspects have to be taken into consideration. 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