Telehealth Visit Feedback
Video-visit quality: connection, privacy comfort, and whether remote care did the job.
4 questions · 1 page · about 2 minutes to answer · fully editable after you start
A telehealth visit succeeds or fails on things in-person care never worries about: the connection holding, the patient having somewhere private to talk, and the nagging question of whether the screen was enough. This survey measures all three, plus whether the patient would choose video again for a similar concern.
The would-choose-again question is your telehealth strategy in one number – it tells you which visit types patients genuinely accept remotely and which quietly demand the exam room.
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Page 1
Your video visit
This survey is about your recent video or phone consultation. Tell us how the technology and the consultation worked for you. It takes about 2 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.How did the practical side go?*
| Problems | Minor issues | Smooth | |
|---|---|---|---|
| Joining the call | |||
| Audio quality | |||
| Video quality | |||
| Having privacy to talk |
Q2.Did the video format meet your needs for this concern?*
- Yes, completely
- Yes, to some extent
- No - I still need an in-person visit
Q3.For a similar concern next time, what would you choose?
- Video visit
- In-person visit
- Either
Q4.Anything about the video visit we should improve?
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