Hospital Discharge Questionnaire
Please fill out this questionnaire to help us ensure your safe discharge and follow-up care.
Patient Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Hospitalization
Current Medications
Do you have any allergies?
Do you have a caregiver at home?
Yes
No
Are you experiencing any symptoms or concerns post-discharge?
Do you understand your discharge instructions?
Yes
No
Additional Comments or Questions
Submit
Should be Empty: