Post-Discharge Follow-Up Survey

Post-Discharge Follow-Up Survey — Form Fields

This healthcare template includes 11 fields. Gather feedback from recently discharged patients about their recovery progress and care experience. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Discharge (text, required)
• Discharge Facility (dropdown selection, required) — options: Hospital, Surgical Center, Rehabilitation Facility, Urgent Care, Emergency Department
• How would you rate your overall care experience? (rating, required)
• Did You Receive Clear Discharge Instructions? (multiple choice, required) — options: Yes, No, Partially
• Have You Experienced Any Complications Since Discharge? (multiple choice, required) — options: Yes, No
• If Yes, Please Describe Complications (long text, optional)
• Have You Filled All Prescribed Medications? (multiple choice, required) — options: Yes, No, Some
• Have You Scheduled a Follow-Up Appointment? (multiple choice, required) — options: Yes, No, In Progress
• Current Recovery Status (dropdown selection, required) — options: Improving, Stable, Worsening, Unsure
• Additional Comments or Concerns (long text, optional)