Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Post-Visit Follow-Up Survey
Patient Name *
Visit Date
____ / ____ / ________
Current Symptom Status
- Improved
- Unchanged
- Worsened
- New symptoms
- Not sure
Medication Adherence
Side Effects Experienced
Prescriptions Filled
- Yes
- No
- Not sure
- Not applicable
Follow-Up Tests Scheduled
- Yes
- No
- Not sure
- Not applicable
Pain Level
Unanswered Questions
Additional Concerns
Post-Visit Follow-Up Survey template from formisoft.com. formisoft.com/intake-templates/post-visit-follow-up