Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Telehealth Experience Survey
Visit Date
____ / ____ / ________
Technology Ease of Use
- Very easy
- Easy
- Neither easy nor difficult
- Difficult
- Very difficult
- Not applicable
Audio Quality
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Video Quality
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Technical Difficulties
Provider Engagement
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Privacy Comfort Level
Effectiveness vs In-Person
- More effective
- About the same
- Less effective
- I have not had an in-person visit
Would Use Telehealth Again
- Yes
- No
- Not sure
- Not applicable
Suggestions for Improvement
Telehealth Experience Survey template from formisoft.com. formisoft.com/intake-templates/telehealth-experience-survey