Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Patient-Reported Health Outcomes

Tracks patients' general, physical, emotional and social health and how their treatment has changed it over time.

Preview

Healthcare · Patient. All Healthcare templates

Questions in this template

Your General Health

  1. Thank you for taking part. This questionnaire asks how your health has been, mostly over the past four weeks, so that we can track the results of your care.

  2. In general, how would you describe your health?

    Choose one:

    • Excellent
    • Very good
    • Good
    • Fair
    • Poor

  3. How is your health now compared with a year ago?

    Choose one:

    • Much better
    • Somewhat better
    • About the same
    • Somewhat worse
    • Much worse

Physical Function and Pain

  1. Does your health currently limit you in any of these activities?

    • Strenuous exercise such as running or a sport
    • Going up a flight of stairs
    • Walking for about 15 minutes
    • Washing or dressing yourself

    For each row: choose one:

    • Not limited
    • Limited a little
    • Limited a lot

  2. Over the past four weeks, how much pain have you had on average?

    A number from 0 to 10

  3. In the past four weeks, on how many days did your health stop you from doing your usual activities?

    A number from 0 to 28

Emotional and Social Health

  1. Over the past four weeks, how much of the time have you...

    • Felt calm and relaxed
    • Felt low or down
    • Had plenty of energy

    For each row: choose one:

    • None of the time
    • A little of the time
    • Some of the time
    • Most of the time
    • All of the time

  2. Over the past four weeks, how much has your health limited the time you spend with friends or family?

    Choose one:

    • Not at all
    • Slightly
    • Moderately
    • Quite a bit
    • Extremely

Your Care and Its Results

  1. Have you received treatment from us in the past three months?

    Choose one:

    • Yes
    • No

  2. Since starting this treatment, how has your health changed?

    Condition: Only for patients treated recently

    Choose one:

    • Much better
    • Somewhat better
    • No change
    • Somewhat worse
    • Much worse

  3. How satisfied are you with the results of your care so far?

    Condition: Only for patients treated recently

    Choose one:

    • Very satisfied
    • Satisfied
    • Neither satisfied nor dissatisfied
    • Dissatisfied
    • Very dissatisfied

  4. How confident do you feel about managing your own health day to day?

    Choose one:

    • Not at all confident
    • Slightly confident
    • Moderately confident
    • Very confident
    • Extremely confident

  5. Is there anything else about your health or your care that you would like to tell us? (optional)

    Open answer