Customer Health Tracker Form
Track and review customer wellness and engagement status for proactive success management.
Customer Name
*
First Name
Last Name
Company / Organization
*
Customer Email
*
example@example.com
Current Engagement Status
*
Active
Onboarding
At Risk
Inactive
Overall Satisfaction Level
*
1
2
3
4
5
Date of Last Customer Check-In
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Method
Please Select
Email
Phone
In-app Messaging
Video Call
Other
Current Support Needs
Technical Support
Training
Billing
None
Other
Customer Health Score (1 = Poor, 10 = Excellent)
*
1
1
2
3
4
5
6
7
8
9
10
10
1 is 1, 10 is 10
Key Feedback, Notes, or Action Items
Submit
Should be Empty: