Treatment Received
Treatment Date
Symptom Improvement Rating
Pain Level Compared to Baseline
Functional Status Change
Daily Activity Ability
Side Effects Experienced
Sleep Quality Change
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Treatment Outcome Survey
Patient-reported outcome survey measuring treatment effectiveness, symptom improvement, functional status changes, and overall satisfaction with treatment results. Supports PRO data collection for quality programs.
2 pages•12 fields•HIPAA-ready
Appointment Time
Arrival to Check-In Wait
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Check-In to Exam Room Wait
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Exam Room to Provider Wait
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Were You Informed of Delays
Wait Time Acceptability
Impact on Overall Experience
Suggestions to Reduce Wait
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Wait Time Feedback Survey
Focused survey on patient wait times throughout the visit, from arrival through check-out. Identifies bottlenecks in patient flow and measures the impact of wait times on overall satisfaction.
1 page•8 fields•HIPAA-ready
