Clinical · free template

Discharge Follow-Up Form

Post-discharge check-in covering recovery so far, medication started or stopped, wound or symptom concerns, support at home and follow-up needs.

A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 16 questions, 2 pages, 3 conditional rules.

Questions: 16
Pages: 2
Layouts: classic · card
Time to complete: ≈ 5 min
Conditional rules: 3

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Ready to publish

Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Discharge Follow-Up Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.

Small teams who need a reliable intake process working in healthcare & clinical.
Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
Anyone replacing chasing missing details over email with one structured record per enquiry.
Respondents are the people you send it to — the form asks them 16 questions across 2 screens.
Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.

11 questions are required, so submissions arrive complete instead of needing a follow-up email.
It captures a phone number for urgent follow-up.
It pins the request to a specific date.
It allows multiple selections without free text.
Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1Press “Use this template” — a fresh copy of Discharge Follow-Up Form lands in your workspace, ready to edit.
2Rename or delete any question, and change what is required. Nothing here is fixed.
3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

Features conditional validation: if “How are you feeling compared with discharge day?” is Worse, “What is worse?” becomes mandatory before the form can be sent.
Features conditional validation: if “Did you collect and start the medication you were sent home with?” is No, “What stopped you?” becomes mandatory before the form can be sent.
Features advanced show logic: if “Do you know when your follow-up appointment is?” is No, the form dynamically exposes “Would you like someone to call you?”. Otherwise that question never appears.
All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

The days after a discharge are when small problems turn into readmissions, and most of them are visible to the patient before they are visible to anyone else. This follow-up form asks the questions that surface them. It records how the patient feels compared with the day they left, whether they collected and started the medication they were sent home with, whether anything they used to take was stopped, and whether they have noticed anything about a wound, breathing, pain or appetite that concerns them. It then asks about the practical side that clinical notes rarely capture: whether someone is at home with them, whether they have managed to eat, wash and move around, and whether they know who to contact and when their follow-up appointment is. Not knowing that last one is a common and entirely fixable cause of an emergency presentation. Answers that suggest a concern raise a short free-text box for detail, and the whole form is short enough to complete by phone with a patient who is tired.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Since you came home

Patient full namerequired
Date of birthrequired
Date you came homerequired
How are you feeling compared with discharge day?required
What is worse?
Did you collect and start the medication you were sent home with?required
What stopped you?
Anything you are concerned about?required
Tell us about it

Page 2 — At home

Is someone at home with you?required
What are you managing on your own?required
Do you know who to contact if you are worried?required
Do you know when your follow-up appointment is?required
Would you like someone to call you?required
Best number to call
Anything else you want the team to know

16 questions in total.

Example of a completed discharge follow-up form

A sample check-in showing how a patient reports on recovery a few days after leaving hospital.

Patient full name: Elena Popescu
Date of birth: 16/03/1965
Date you came home: 12/04/2026
How are you feeling compared with discharge day?: Better
Did you collect and start the medication you were sent home with?: Yes
Anything you are concerned about?: Nothing at the moment
Is someone at home with you?: Yes, all the time
Do you know when your follow-up appointment is?: Yes
Would you like someone to call you?: No, thank you

Sample data — no real people, addresses or records are shown.

How the form changes as it's filled in

This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “How are you feeling compared with discharge day?”

Makes answers required
If “How are you feeling compared with discharge day?” is Worse, “What is worse?” becomes required before the form can be submitted.

Driven by “Did you collect and start the medication you were sent home with?”

Makes answers required
If “Did you collect and start the medication you were sent home with?” is No, “What stopped you?” becomes required before the form can be submitted.

Driven by “Do you know when your follow-up appointment is?”

Reveals questions
If “Do you know when your follow-up appointment is?” is No, the form reveals “Would you like someone to call you?”.

Set it up step by step

1
Send it on day two or three
Early enough to catch a problem, late enough that the patient has tried to manage at home and knows what is difficult.
2
Read the support answers together
Living alone plus difficulty with stairs and food is a picture that no single clinical answer conveys.
3
Act on the two knowledge questions
Patients who do not know who to contact or when they are seen next are the ones who present at emergency departments.
4
Offer a call, do not assume one
The call-back question makes contact a choice, which means the calls you do make are wanted and answered.

Mistakes to avoid

Asking only about symptoms and missing whether the patient can actually feed and wash themselves.
Sending the follow-up two weeks after discharge, by which point it is a satisfaction survey.
Collecting concerns without a same-day route for someone to act on them.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Review submissions the same working day, call everyone who asked and everyone reporting they feel worse, and confirm the follow-up appointment date to anyone who does not know it.

Works in both layouts

Browse classic templates Browse card templates

Forms that overlap this one

These pages cover the same subject ground as the discharge follow-up form, matched on the words people actually search for.

Privacy & compliance

This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.

Frequently asked questions

Can a nurse complete it over the phone?

Yes, and that is often the point — the wording is written to be read aloud to a patient who is tired, and the answers still record consistently.

How does it relate to the Home Health Assessment?

This is the short check in the first week. The Home Health Assessment is the fuller three-page visit covering the home environment, mobility and care needs in detail.

Should it be used for urgent problems?

No. Say so in the intro and give the number to call instead; the form is reviewed during working hours and is not a substitute for urgent care.

Can we send it more than once?

Yes. A second submission at two weeks shows direction of travel, and comparing the same questions is more useful than adding new ones.

Is the Discharge Follow-Up Form template free to use?

Yes. You can preview and test Discharge Follow-Up Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Discharge Follow-Up Form template ask for?

It asks 16 questions across 2 pages, 11 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Discharge Follow-Up Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this healthcare & clinical form work?

3 conditional rules ship with the template: Features conditional validation: if “How are you feeling compared with discharge day?” is Worse, “What is worse?” becomes mandatory before the form can be sent. Features conditional validation: if “Did you collect and start the medication you were sent home with?” is No, “What stopped you?” becomes mandatory before the form can be sent. Features advanced show logic: if “Do you know when your follow-up appointment is?” is No, the form dynamically exposes “Would you like someone to call you?”. Otherwise that question never appears. All rules are editable in the Logic tab.

Where do responses to the Discharge Follow-Up Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Discharge Follow-Up Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

More forms teams pair with the discharge follow-up form.

Related categories

All Healthcare & Clinical templates

Discharge Follow-Up Form

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