Oncology Patient Post-Discharge Follow-up Questionnaire

Patient Information

Full Name Patient ID / MRN Discharge Date Contact Information

Health Status

How are you feeling since discharge? Have you had any of the following symptoms? (Check all that apply) Other symptoms

Medication

Are you taking your prescribed medication as directed? Yes No Partly If not, please describe any issues

Follow-Up Care

Have you scheduled/attended your follow-up appointments? Yes No Scheduled Do you have any questions or concerns for your care team?