Discharge Planning Questionnaire
A simple discharge planning form to help coordinate follow-up, home support, and preparation before discharge. Use the exact title "Discharge Planning Questionnaire" consistently throughout the form.
Patient and Discharge Details
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Unit / Department
*
Please Select
Medical
Surgical
Orthopedics
Cardiology
Neurology
Maternity
Rehabilitation
Emergency
Other
Preferred Contact Method for Follow-Up
*
Phone
Email
Text Message
Other
Care Needs and Home Support
Current living situation after discharge
*
Lives alone
Lives with family
Lives with friends/roommates
Assisted living
Skilled nursing facility
Other
Will someone be available to help at home?
*
Yes
No
Mobility or transportation needs after discharge
Equipment or home support needed
Follow-Up and Preparation
Follow-up appointment readiness
*
Ready to schedule now
Prefer a specific date/time
Need help coordinating
Other
Preferred pharmacy or medication pickup method
Questions or concerns about discharge
Submit
Should be Empty: