Telehealth Visit Rating
Capture comprehensive feedback on telehealth experiences with this dual-focus survey. Evaluate both the technical aspects (video quality, audio clarity, platform usability) and the care quality (provider communication, diagnosis clarity, follow-up instructions). Features conditional logic that adapts questions based on connection quality, making it perfect for healthcare providers optimizing their virtual care delivery.
Try the Form
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
export function telehealthFeedback(form: FormTs) {
// Telehealth Visit Feedback - Virtual healthcare experience survey
// Demonstrates: Slider, StarRating, EmojiRating, RatingScale (NPS), MatrixQuestion, ThumbRating, conditional visibility
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Telehealth Visit Feedback',
computedValue: () => 'Help us improve your virtual care experience',
customStyles: {
backgroundColor: '#0891b2',
color: 'white',
padding: '24px',
borderRadius: '12px',
textAlign: 'center'
}
});
});
form.addRow(row => {
row.addTextPanel('confidentiality', {
computedValue: () => 'Your feedback is confidential and will be used to improve our telehealth services.',
customStyles: {
backgroundColor: '#ecfeff',
padding: '12px',
borderRadius: '8px',
fontSize: '14px',
textAlign: 'center',
fontStyle: 'italic'
}
});
});
// ============================================
// SECTION 1: Visit Information
// ============================================
const visitInfo = form.addSubform('visitInfo', {
title: 'Visit Details'
});
visitInfo.addRow(row => {
row.addDropdown('visitType', {
label: 'Type of Visit',
options: [
{ id: 'primary-care', name: 'Primary Care' },
{ id: 'specialist', name: 'Specialist Consultation' },
{ id: 'mental-health', name: 'Mental Health' },
{ id: 'follow-up', name: 'Follow-up Visit' },
{ id: 'urgent', name: 'Urgent Care' },
{ id: 'other', name: 'Other' }
],
placeholder: 'Select visit type',
isRequired: true
}, '1fr');
row.addDropdown('device', {
label: 'Device Used',
options: [
{ id: 'smartphone', name: 'Smartphone' },
{ id: 'tablet', name: 'Tablet' },
{ id: 'laptop', name: 'Laptop' },
{ id: 'desktop', name: 'Desktop Computer' }
],
placeholder: 'Select device'
}, '1fr');
});
visitInfo.addRow(row => {
row.addRadioButton('firstTelehealth', {
label: 'Was this your first telehealth visit?',
options: [
{ id: 'yes', name: 'Yes, this was my first virtual visit' },
{ id: 'no-first-here', name: 'No, but first with this provider' },
{ id: 'no-experienced', name: 'No, I have used telehealth before' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 2: Technical Quality
// ============================================
const techSection = form.addSubform('technical', {
title: 'Technical Quality',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null,
customStyles: () => {
const videoQ = techSection.slider('videoQuality')?.value() || 0;
const audioQ = techSection.slider('audioQuality')?.value() || 0;
const avg = (videoQ + audioQ) / 2;
if (avg >= 80) return { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' };
if (avg >= 50) return { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' };
if (avg > 0) return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
return { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' };
}
});
techSection.addRow(row => {
row.addTextPanel('techInstructions', {
computedValue: () => 'Rate the technical aspects of your video visit (0 = Very Poor, 100 = Excellent)',
customStyles: {
fontSize: '14px',
color: '#64748b',
marginBottom: '8px'
}
});
});
techSection.addRow(row => {
row.addSlider('videoQuality', {
label: () => {
const val = techSection.slider('videoQuality')?.value() || 0;
if (val >= 80) return 'Video Quality: Excellent';
if (val >= 60) return 'Video Quality: Good';
if (val >= 40) return 'Video Quality: Fair';
if (val >= 20) return 'Video Quality: Poor';
return 'Video Quality';
},
min: 0,
max: 100,
step: 5,
defaultValue: 75,
unit: '%',
showValue: true
}, '1fr');
row.addSlider('audioQuality', {
label: () => {
const val = techSection.slider('audioQuality')?.value() || 0;
if (val >= 80) return 'Audio Quality: Excellent';
if (val >= 60) return 'Audio Quality: Good';
if (val >= 40) return 'Audio Quality: Fair';
if (val >= 20) return 'Audio Quality: Poor';
return 'Audio Quality';
},
min: 0,
max: 100,
step: 5,
defaultValue: 75,
unit: '%',
showValue: true
}, '1fr');
});
techSection.addRow(row => {
row.addSlider('connectionStability', {
label: () => {
const val = techSection.slider('connectionStability')?.value() || 0;
if (val >= 80) return 'Connection Stability: Very Stable';
if (val >= 60) return 'Connection Stability: Mostly Stable';
if (val >= 40) return 'Connection Stability: Some Issues';
return 'Connection Stability: Unstable';
},
min: 0,
max: 100,
step: 5,
defaultValue: 75,
unit: '%',
showValue: true
});
});
// Technical issues section
const techIssues = form.addSubform('techIssues', {
title: 'Technical Issues Encountered',
isVisible: () => {
const videoQ = techSection.slider('videoQuality')?.value() || 100;
const audioQ = techSection.slider('audioQuality')?.value() || 100;
const conn = techSection.slider('connectionStability')?.value() || 100;
return videoQ < 60 || audioQ < 60 || conn < 60;
},
customStyles: {
backgroundColor: '#fef3c7',
padding: '16px',
borderRadius: '8px'
}
});
techIssues.addRow(row => {
row.addCheckboxList('issuesEncountered', {
label: 'What issues did you experience?',
options: [
{ id: 'frozen-video', name: 'Video froze or lagged' },
{ id: 'pixelated', name: 'Pixelated or blurry video' },
{ id: 'no-video', name: 'Video did not work' },
{ id: 'audio-cutting', name: 'Audio kept cutting out' },
{ id: 'echo', name: 'Echo or feedback' },
{ id: 'no-audio', name: 'Could not hear provider' },
{ id: 'disconnected', name: 'Got disconnected' },
{ id: 'login-issues', name: 'Trouble joining the call' }
],
orientation: 'vertical'
});
});
techIssues.addRow(row => {
row.addTextarea('techComments', {
label: 'Additional technical comments',
placeholder: 'Describe any other technical issues...',
rows: 2,
autoExpand: true
});
});
// ============================================
// SECTION 3: Platform Usability
// ============================================
const usabilitySection = form.addSubform('usability', {
title: 'Platform Experience',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null
});
usabilitySection.addRow(row => {
row.addMatrixQuestion('platformRating', {
label: 'Rate the telehealth platform',
rows: [
{ id: 'ease-join', label: 'Easy to join the visit', isRequired: true },
{ id: 'waiting-room', label: 'Virtual waiting room experience', isRequired: false },
{ id: 'navigation', label: 'Easy to navigate/use controls', isRequired: false },
{ id: 'notifications', label: 'Clear appointment reminders', isRequired: false }
],
columns: [
{ id: '1', label: 'Poor' },
{ id: '2', label: 'Fair' },
{ id: '3', label: 'Good' },
{ id: '4', label: 'Very Good' },
{ id: '5', label: 'Excellent' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 4: Care Quality
// ============================================
const careSection = form.addSubform('care', {
title: 'Quality of Care',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null,
customStyles: () => {
const rating = careSection.starRating('providerRating')?.value() || 0;
if (rating >= 4) return { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' };
if (rating >= 3) return { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' };
if (rating >= 1) return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
return { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' };
}
});
careSection.addRow(row => {
row.addStarRating('providerRating', {
label: 'How would you rate your healthcare provider?',
maxStars: 5,
size: 'lg',
alignment: 'center',
showConfettiOnMax: true
});
});
careSection.addRow(row => {
row.addMatrixQuestion('careQuality', {
label: 'Rate the following aspects of your care:',
rows: [
{ id: 'listening', label: 'Provider listened to my concerns', isRequired: true },
{ id: 'explanation', label: 'Clear explanation of diagnosis/treatment', isRequired: true },
{ id: 'questions', label: 'Opportunity to ask questions', isRequired: false },
{ id: 'time', label: 'Adequate time for the visit', isRequired: false },
{ id: 'empathy', label: 'Provider showed empathy and care', isRequired: false },
{ id: 'instructions', label: 'Clear follow-up instructions', isRequired: false }
],
columns: [
{ id: '1', label: 'Poor' },
{ id: '2', label: 'Fair' },
{ id: '3', label: 'Good' },
{ id: '4', label: 'Very Good' },
{ id: '5', label: 'Excellent' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 5: Overall Experience
// ============================================
const overallSection = form.addSubform('overall', {
title: 'Overall Experience',
isVisible: () => careSection.starRating('providerRating')?.value() !== null
});
overallSection.addRow(row => {
row.addEmojiRating('overallFeeling', {
label: 'How do you feel about your telehealth experience?',
preset: 'satisfaction',
size: 'lg',
showLabels: true,
alignment: 'center'
});
});
overallSection.addRow(row => {
row.addThumbRating('teleVsInPerson', {
label: 'Would you use telehealth again instead of an in-person visit for similar concerns?',
showLabels: true,
upLabel: 'Yes, telehealth works for me',
downLabel: 'No, prefer in-person',
alignment: 'center',
size: 'lg'
});
});
overallSection.addRow(row => {
row.addRatingScale('recommendNPS', {
preset: 'nps',
label: 'How likely are you to recommend our telehealth services?',
showSegmentColors: true,
showCategoryLabel: true,
alignment: 'center',
showConfettiOnPromoter: true
});
});
// ============================================
// SECTION 6: Conditional Follow-up
// ============================================
const positiveSection = form.addSubform('positiveFollowup', {
title: 'What We Did Well',
isVisible: () => {
const nps = overallSection.ratingScale('recommendNPS')?.npsCategory();
return nps === 'promoter';
},
customStyles: { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' }
});
positiveSection.addRow(row => {
row.addSuggestionChips('positives', {
label: 'What did you appreciate most?',
suggestions: [
{ id: 'convenience', name: 'Convenience' },
{ id: 'no-travel', name: 'No travel needed' },
{ id: 'quick-access', name: 'Quick access to care' },
{ id: 'comfort', name: 'Comfort of home' },
{ id: 'provider', name: 'Great provider' },
{ id: 'easy-tech', name: 'Easy technology' },
{ id: 'time-saved', name: 'Time saved' },
{ id: 'safety', name: 'Reduced exposure risk' }
],
max: 4,
alignment: 'center'
});
});
const improvementSection = form.addSubform('improvementFollowup', {
title: 'How Can We Improve?',
isVisible: () => {
const nps = overallSection.ratingScale('recommendNPS')?.npsCategory();
return nps === 'detractor' || nps === 'passive';
},
customStyles: { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' }
});
improvementSection.addRow(row => {
row.addSuggestionChips('improvements', {
label: 'What areas need improvement?',
suggestions: [
{ id: 'video-quality', name: 'Video quality' },
{ id: 'audio-quality', name: 'Audio quality' },
{ id: 'platform', name: 'Platform usability' },
{ id: 'wait-time', name: 'Waiting time' },
{ id: 'provider-manner', name: 'Provider bedside manner' },
{ id: 'visit-length', name: 'Visit length' },
{ id: 'follow-up', name: 'Follow-up process' },
{ id: 'prefer-inperson', name: 'Prefer in-person visits' }
],
max: 4,
alignment: 'center'
});
});
improvementSection.addSpacer();
improvementSection.addRow(row => {
row.addTextarea('improvementComments', {
label: 'Please share specific suggestions for improvement',
placeholder: 'Your feedback helps us improve...',
rows: 3,
autoExpand: true
});
});
// ============================================
// SECTION 7: Summary
// ============================================
const summarySection = form.addSubform('summary', {
title: 'Feedback Summary',
isVisible: () => overallSection.ratingScale('recommendNPS')?.value() !== null
});
summarySection.addRow(row => {
row.addTextPanel('summaryContent', {
computedValue: () => {
const visitType = visitInfo.dropdown('visitType')?.value() || '';
const providerRating = careSection.starRating('providerRating')?.value();
const videoQ = techSection.slider('videoQuality')?.value() || 0;
const audioQ = techSection.slider('audioQuality')?.value() || 0;
const nps = overallSection.ratingScale('recommendNPS')?.npsCategory();
const useTelehealth = overallSection.thumbRating('teleVsInPerson')?.value();
if (!providerRating) return '';
const visitTypes: Record<string, string> = {
'primary-care': 'Primary Care',
'specialist': 'Specialist',
'mental-health': 'Mental Health',
'follow-up': 'Follow-up',
'urgent': 'Urgent Care',
'other': 'Other'
};
const avgTech = Math.round((videoQ + audioQ) / 2);
const techRating = avgTech >= 80 ? 'Excellent' : avgTech >= 60 ? 'Good' : avgTech >= 40 ? 'Fair' : 'Poor';
let summary = `TELEHEALTH FEEDBACK\n`;
summary += `${'═'.repeat(25)}\n\n`;
if (visitType) {
summary += `Visit Type: ${visitTypes[visitType] || visitType}\n`;
}
summary += `\nProvider Rating: ${'★'.repeat(providerRating)}${'☆'.repeat(5 - providerRating)} (${providerRating}/5)\n`;
summary += `Technical Quality: ${techRating} (${avgTech}%)\n`;
if (nps) {
const emoji = nps === 'promoter' ? '🎉' : nps === 'passive' ? '😐' : '😟';
summary += `\n${emoji} NPS: ${nps.charAt(0).toUpperCase() + nps.slice(1)}\n`;
}
if (useTelehealth) {
summary += `\nWould use again: ${useTelehealth === 'up' ? 'Yes' : 'No'}`;
}
return summary;
},
customStyles: () => {
const nps = overallSection.ratingScale('recommendNPS')?.npsCategory();
const baseStyles = {
padding: '16px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '13px'
};
if (nps === 'promoter') {
return { ...baseStyles, backgroundColor: '#d1fae5', borderLeft: '4px solid #10b981' };
} else if (nps === 'passive') {
return { ...baseStyles, backgroundColor: '#fef3c7', borderLeft: '4px solid #f59e0b' };
} else if (nps === 'detractor') {
return { ...baseStyles, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
return { ...baseStyles, backgroundColor: '#f8fafc', borderLeft: '4px solid #0891b2' };
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Feedback',
isVisible: () => overallSection.ratingScale('recommendNPS')?.value() !== null
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank You for Your Feedback!',
message: 'Your feedback helps us improve our telehealth services. We appreciate you taking the time to share your experience.'
});
}
Frequently Asked Questions
How do you measure telehealth technical quality?
The form uses slider ratings for video quality, audio clarity, and connection stability. It also captures specific technical issues encountered and platform usability. This data helps identify IT infrastructure improvements needed.
Is this form HIPAA compliant?
The form template itself doesn't collect PHI (Protected Health Information). It focuses on experience feedback rather than medical information. However, ensure your form hosting platform and data storage comply with HIPAA requirements for your organization.
How do you separate technical issues from care quality?
The form uses distinct sections for technical experience and clinical care. This separation ensures that poor internet connectivity doesn't unfairly impact provider ratings, while still capturing the full patient experience.
When should telehealth feedback be collected?
Best practice is to send the survey within 24 hours of the virtual visit, ideally immediately after. The experience is fresh in patients' minds, and timely feedback allows quick resolution of any issues.
Can this be used for mental health telehealth?
Yes, the form is suitable for all telehealth specialties including mental health, primary care, and specialist consultations. You can customize the care quality questions to focus on aspects most relevant to your specialty.