Questionnaire template
Treatment Readiness and Consent
Checks a patient's understanding of, confidence in and concerns about a planned treatment, and records their consent decision.
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Healthcare · Patient consent. All Healthcare templates
Questions in this template
About You
Thank you for taking a few minutes before your treatment begins. Your answers show us how ready you feel and whether anything needs explaining further.
-
In what year were you born?
A number from 1910 to 2026
-
What is your gender?
Choose one:
- Female
- Male
- Non-binary
- Prefer not to say
-
Do you have any other health conditions at the moment?
Choose one:
- Yes
- No
-
Which health conditions do you have?
Condition: Only for patients with existing conditions
Open answer
Understanding Your Treatment
-
Do you feel you understand what the treatment will involve?
Choose one:
- Yes
- Partly
- No
-
Which parts of the treatment would you like explained in more detail?
Condition: Only when the treatment is not fully understood
Open answer
How You Feel About the Treatment
-
How much do you agree with each statement?
- I expect the benefits of this treatment to be worth its possible side effects.
- I have confidence in my doctor's recommendation.
- I am ready to begin the treatment straight away.
For each row: choose one:
- Strongly disagree
- Disagree
- Neither agree nor disagree
- Agree
- Strongly agree
Your Concerns
-
Is anything about the treatment worrying you? Please describe it here. (optional)
Open answer
Your Decision
-
With everything you now know, do you agree to have this treatment?
Choose one:
- Yes
- No
- I need more time to decide
If you agree to go ahead, your care team will ask you to sign the formal consent form separately.