Telemedicine Consultant Evaluation Form
Consultant Name
First Name
Last Name
Specialty
Location
Examination Start Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Examination End Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
1. How many times you have communicated on telemedicine network?
Never
1-5 times
5+ times
2. What is the purpose of the appointment?
Ongoing Care
Consultation
Pre-op Visit
Post-op Visit
Other
3. Is the internet/technology enough for telecommunication?
Yes
No
N/A
4. Is in-person visit required for the diagnosis?
Yes
No
N/A
5. Patient Disposition - select all that apply
I will manage the treatment
Further testing is needed
Patient is discharged from the care
In-person treatment is needed
Patient is recommended to see another professional
Other
6. Please state that whether you agree that decision-making during telemedicine is successful.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
7. Please state that whether you agree that using telemedicine technologies makes the treatment process easier.
Disagree
1
2
3
4
Agree
5
1 is Disagree, 5 is Agree
8. Additional Comments
Submit
Should be Empty: