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Questionnaire template

Patient Health Improvement Feedback

Measures patients' reported health changes, goal progress, plan adherence and support during a course of care.

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Healthcare · Patient. All Healthcare templates

Questions in this template

Your Care

  1. We would like to know how your health has changed since you started your current care. Your answers help us see what is working and where we can support you better.

  2. What is the main reason you are receiving care?

    Choose one:

    • A long-term condition
    • Recovery from an injury or operation
    • A short-term illness
    • Mental health
    • Prevention or lifestyle change
    • Other

  3. How long have you been receiving this care?

    Choose one:

    • Less than 1 month
    • 1 to 3 months
    • 3 to 12 months
    • More than 12 months

Changes in Your Health

  1. Compared with when your care began, how is your health now?

    Choose one:

    • Much better
    • A little better
    • About the same
    • A little worse
    • Much worse

  2. Since your care began, how has each of these changed?

    • Pain
    • Ability to move around
    • Energy
    • Sleep
    • Mood
    • Ability to do everyday activities

    For each row: choose one:

    • Much better
    • A little better
    • No change
    • A little worse
    • Much worse
    • Not applicable

  3. How far have you reached the health goals agreed with your care team?

    Choose one:

    • Fully reached
    • Mostly reached
    • Partly reached
    • Not reached
    • No goals were agreed

Following Your Treatment Plan

  1. How often have you been able to follow your treatment plan?

    Choose one:

    • All of the time
    • Most of the time
    • Some of the time
    • Rarely or never

  2. What has made it harder to follow your plan?

    Condition: Only when the plan was not always followed

    Choose any that apply:

    • Cost
    • Side effects
    • Forgetting
    • Lack of time
    • Instructions were unclear
    • I did not see a benefit
    • Other

  3. What else made it harder?

    Condition: Only when Other was selected

    Open answer

  4. How much do you think your care has contributed to any change in your health?

    Choose one:

    • A great deal
    • Somewhat
    • A little
    • Not at all

Support and Next Steps

  1. How much do you agree with each statement about your care team?

    • They explained my progress clearly.
    • They listened to my concerns.
    • They involved me in decisions about my care.

    For each row: choose one:

    • Strongly disagree
    • Disagree
    • Neither agree nor disagree
    • Agree
    • Strongly agree

  2. How confident are you that you can look after your own health from now on?

    Choose one:

    • Very confident
    • Fairly confident
    • Not very confident
    • Not at all confident

  3. How likely are you to recommend this service to a friend or relative who needed similar care?

    A number from 0 to 10

  4. What would help your health improve further?

    Open answer