Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Treatment Outcome Survey
Your information
Treatment Received
Treatment Date
____ / ____ / ________
Symptom Improvement Rating
- Much improved
- Somewhat improved
- Unchanged
- Somewhat worse
- Much worse
Pain Level Compared to Baseline
- Less pain
- About the same
- More pain
- Not applicable
Functional Status Change
- Improved
- Unchanged
- Worsened
- Not sure
Daily Activity Ability
Additional details
Side Effects Experienced
Sleep Quality Change
- Improved
- Unchanged
- Worsened
- Not sure
Expectations Met
- Yes
- No
- Not sure
- Not applicable
Would Choose Treatment Again
- Yes
- No
- Not sure
- Not applicable
Overall Outcome Satisfaction
- Very satisfied
- Satisfied
- Neither satisfied nor dissatisfied
- Dissatisfied
- Very dissatisfied
- Not applicable
Additional Comments
Treatment Outcome Survey template from formisoft.com. formisoft.com/intake-templates/treatment-outcome-survey