Patient Discharge Experience Questionnaire
Please provide your feedback on your discharge experience to help us improve our services.
Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the clarity of the discharge instructions?
1
2
3
4
5
How satisfied were you with the discharge process?
1
2
3
4
5
Were your questions and concerns adequately addressed?
Yes
No
Partially
Please provide any additional comments or suggestions regarding your discharge experience.
Submit
Should be Empty: