This printable hospital discharge survey helps wards and discharge teams capture honest feedback from every patient as they leave, in 15 quick questions across two pages. It reaches people who never open an email or patient portal, and it takes about two minutes to complete at the bedside or at the ward desk.
What this survey measures
The survey focuses on the moments that shape a safe, confident discharge. A rating grid asks whether staff explained the condition and treatment clearly, whether discharge instructions were understood, whether the patient knew who to contact with questions, whether pain was well managed, and whether they felt treated with dignity and respect in a clean, comfortable ward. A likelihood-to-recommend question gives you a simple score to track over time, and an open comment box captures anything the fixed questions miss.
How to use it on paper
Hand the form to patients as their discharge paperwork is prepared, or leave copies at the ward desk with a drop box for completed sheets. Patients fill the checkboxes with a blue or black pen. Collect the forms and scan them in batches: PaperSurvey reads the checkbox answers with optical mark recognition and converts handwritten comments to text automatically, so results appear in your dashboard without any manual data entry.
Customize this template
Add your hospital logo, reword statements to match your ward or specialty, and add or remove questions to cover medication counseling, follow-up appointments, or transport. The paper layout reflows automatically as you edit, and every copy you print stays scannable.
Preview the PDF above, or use this template to start collecting discharge feedback today.