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The Patient Portal Feedback Form is available in Word (16 KB)

Instructions: These questions are meant to guide your collection of feedback as you observe a patient using your portal. They are not intended for distribution directly to patients. Allow the patient to navigate the site. Ask if they could show you how to do something while on the practice’s portal (e.g., request a prescription refill or make an appointment). After they are done, ask the following questions and use this form to record responses.

1. Is this the first time you have visited our patient portal? ☐ Yes    ☐ No

If Yes: Why haven’t you used the patient portal before? ______________

2. How often do you use the Internet?
☐ Every day 
☐ Several times per week
☐ �鶹��ý once per week
☐ Less than once per week
☐ Never or hardly ever

3. Did anyone in the practice ask you if you’d like help signing into and using the patient portal? 
☐ Yes 
If Yes, did you receive any training on the portal? ☐Yes ☐No 
☐ No 
If No, would you have liked training on the portal? ☐Yes ☐No 

4. Is it easy to sign into the patient portal? 
☐ Yes
☐ No 
If No, what would make it easier to sign in? __________________________

5. Is it clear how to get from the home page to the pages you want to use? 
☐ Yes
☐ No 
If No, what are you looking for that you cannot find from the home page?_____________________________________________________

6. Is the site easy to read?
☐ Yes
☐ No 
If No, what was hard to read and why? ____________________________________

7. Is the information you want on the site? 
☐ Yes
☐ No 
If No, what information would you like to have on the site?  
______________________________________________________________

8. Is it easy to find the information you want? 
☐ Yes
☐ No 
If No, what was hard to find and why? 
______________________________________________________________

9. Is the information on the site easy to understand? 
☐ Yes
☐ No 
If No, what was hard to understand and why?  
______________________________________________________________

10. Now that we have gone through the patient portal, would you use it again? 
☐ Yes
☐ No 
If No, why not? What would make it more likely that you would use the portal? ________________________________________________________

Ask the patient to perform a task on the portal (e.g., find information on a particular topic, look up recent lab results, request a prescription refill). Use this space to note how easy or hard it was for the patient to perform the task.
_______________________________________