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Questionnaire template

Patient Understanding and Consent Assessment

Measures how well patients understood a proposed treatment and whether their consent decision felt informed and voluntary.

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Healthcare · Patient consent. All Healthcare templates

Questions in this template

Your Treatment

  1. Before a treatment or test, we aim to make sure you understand it and feel free to decide. Please think about your most recent consent discussion when answering.

  2. What did you agree to, or were asked to agree to?

    Choose one:

    • An operation or procedure
    • A medicine
    • A test or scan
    • Therapy or rehabilitation
    • Other

  3. Please describe it briefly.

    Condition: Only when Other was selected

    Open answer

  4. Who mainly explained it to you?

    Choose one:

    • Doctor or surgeon
    • Nurse
    • Another health professional
    • Not sure

Your Understanding

  1. How well did you understand each of the following?

    • Why it was recommended for you
    • What would happen during it
    • The main risks
    • The expected benefits
    • Other options, including not going ahead
    • What recovery or aftercare would involve

    For each row: choose one:

    • Fully
    • Mostly
    • Partly
    • Not at all

  2. In your own words, what is the main purpose of this treatment or test?

    Open answer

  3. Were your questions answered in a way you could understand?

    Choose one:

    • Yes, all of them
    • Some of them
    • No
    • I did not have any questions

Making the Decision

  1. How much do you agree with each statement?

    • I had enough time to decide.
    • I felt free to say no.
    • I could involve family or friends if I wished.
    • I know I can change my mind before it takes place.

    For each row: choose one:

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

  2. Were you given written information to take away?

    Choose one:

    • Yes
    • No
    • Not sure

  3. Did you need an interpreter or other communication support during the discussion?

    Choose one:

    • Yes
    • No

  4. Was that support provided?

    Condition: Only when communication support was needed

    Choose one:

    • Yes, fully
    • Partly
    • No

Overall

  1. How confident are you that the decision you made was right for you?

    Choose one:

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

  2. What would have made the explanation clearer for you?

    Open answer