Telemedicine Patient Evaluation Form
Date
-
Month
-
Day
Year
Date
Patient Information
Patient's Name
First Name
Last Name
Age
Patient’s county of residence
Consult speciality
Appointment purpose
Consult
Pre-Op
Post-Op
Ongoing Care
Patient care setting that best describes your location
Emergency Room (ER)
In-Patient Service
Out-Patient Service
Rural Clinic
Health Department
School Clinic
Mobile Unit
This is the first time I have been seen as a patient on the telemedicine network?
Yes
No
What is your last telemedicine visit was?
Have you been in the hospital since your last telemedicine visit?
Yes
No
1
Rows
2
Number of Patient Hospitalizations in last 6 months
Number of Emergency Room visits in last 6 months
3
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Any thoughts?
The telemedicine encounter was successful
4
5
6
I was satisfied with today’s encounter
7
8
9
Additional comments
Submit
For Office Use Only
Encounter Type
IN= interactive consult
PP= patient present for consult
NP=patient NOT present for consult (such as for TB clinic)
SF= store and forward (such as for ECHOS)
BI= telemetry/biometric monitoring
OT=Other
10
Rows
Agree
Disagree
The telemedicine encounter was successful
11
12
Additional comments
Submit
Should be Empty: