Telehealth Post-Discharge Follow-up Questionnaire
Patient Information
Full Name
Date of Birth
Contact Number
Discharge Details
Date of Discharge
Reason for Hospitalization
Current Symptoms
Are you experiencing any of the following? (Select all that apply)
Pain
Fever
Nausea
Shortness of Breath
None
Other symptoms
Medications
Are you taking your prescribed medications as directed?
Yes
No
If no, please explain
Follow-up Care
Have you scheduled your follow-up appointments?
Yes
No
If no, would you like assistance in scheduling your appointments?
Questions & Additional Comments
Do you have any questions or concerns you'd like to discuss?