Hospital Discharge Patient Follow-Up Survey

Hospital Discharge Patient Follow-Up Survey — Form Fields

This surveys template includes 10 fields. Assess patient recovery progress and satisfaction after hospital discharge. Free to customize and use on ZenBuild.

• Days since discharge (dropdown selection, required) — options: 1-3 days, 4-7 days, 1-2 weeks, 2-4 weeks, More than 1 month
• Quality of Care During Hospital Stay (rating, required)
• Clarity of Discharge Instructions (rating, required)
• Ease of Accessing Post-Discharge Support (rating, required)
• Have you followed your discharge care plan? (multiple choice, required) — options: Yes, fully, Mostly, Partially, No
• Have you needed to return to the hospital or ER since discharge? (multiple choice, required) — options: Yes, No
• Challenges after discharge (checkboxes, optional) — options: Medication Management, Follow-Up Appointments, Pain Management, Transportation, Home Care Needs, None
• Additional feedback for the care team (long text, optional)
• Overall Hospital Experience (rating, required)
• Email for follow-up contact (email, optional)