Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Telehealth Readiness Assessment Survey
Your information
Patient Name *
Available Device Type
- Smartphone
- Tablet
- Computer
- None available
Internet Connection Type
- Home Wi-Fi
- Mobile data
- Public/shared Wi-Fi
- No internet access
- Not sure
Internet Reliability Rating
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Private Space for Video Visit
- Yes
- No
- Not sure
- Not applicable
Prior Video Call Experience
- Yes
- No
- Not sure
- Not applicable
Additional details
Comfort with Health Apps / Portals
Able to Upload Documents / Photos
- Yes
- No
- Not sure
- Not applicable
Need Pre-Visit Tech Assistance
- Yes
- No
- Not sure
- Not applicable
Preferred Visit Modality
- In person
- Video
- Phone
- No preference
Accessibility Needs
Additional Comments
Telehealth Readiness Assessment Survey template from formisoft.com. formisoft.com/intake-templates/telehealth-readiness-survey