FREE ACCOUNT

Healthcare Well-Being Survey Template

Healthcare Well-being Survey Template offers questions about the health and well-being of patients who are 55 years and older. This sample can be edited by the survey maker according to the required details about elderly patients. Some of the question examples of this questionnaire are "Overall, how would you rate the local hospitals in your area?", "What about the amount of social support you receive from your family, friends, etc?", "When you have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs?" et al.


We are conducting a brief public opinion survey of persons 55 years of age and older regarding health care needs. This survey is to be completed by someone who falls into that age category.
Overall, how would you rate the local hospitals in your area?
How would you evaluate your overall health. Would you say you are:
What about the amount of social support you receive from your family, friends, etc? When you have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs?
How often does a close friend or relative visit you in your home?
Which of the following best describes your capacities to perform everyday activities:
Can you get to places out of walking distances:

Can you do your own housework:
Can you go shopping for groceries:
Can you prepare your own meals?

Can you do your own laundry?
Can you manage your own money?
Do you take care of your own appearance, things like combing your hair, shaving, etc?
Do you dress and undress yourself?
In the past 24 hours, how many different kinds of medication have you taken?
If you have taken medication in the last 24 hours, how many of them have been prescribed by your physician?
If you have taken medication in the last 24 hours, do you take your medicine:
Do you or your spouse experience chronic pain? (either ongoing or recurring pain)
If yes, how are you or your spouse currently being treated for chronic pain?
Age category:
Gender:
Number of members residing in your household:
What are your current living arrangements, in terms of your relation to the people you are living with?
Do you own or rent your home?
Employment status:
Marital status:
Thank you.

Health Care Surveys

Medical Examination Services Survey Template

21 questions

Medical Examination Services Survey Template offers questions to evaluate the desirability of medical examination features and customer attitudes of current services. This sample can be edited by the survey maker according to the required details about the medical examination. Some of the question examples of this questionnaire are "Rate the following parameters according to their importance", "How would you rate on each of the following items with your current medical service provider?" et al.

Health Care Surveys

Healthcare Opinion Survey Template

44 questions

Healthcare Opinion Survey Template offers hospital and healthcare organization questions to evaluate quality, affordability levels, availability, and preferences of customers. This sample can be edited by the survey maker according to the required details about the healthcare opinions. Some of the question examples of this questionnaire are "Is there a difference in performance between the available hospitals in this area?", "How satisfied are you with the following factors" et al.

Health Care Surveys

Physician Practices Survey Template

47 questions

Physician Practices Survey Template offers questions for evaluation of hospital and the services provided. This sample can be edited by the survey maker according to the required details about hospitals and their services. Some of the question examples of this questionnaire are "What is your medical specialty", "When a patient needs hospital care, who selects the hospital or other care facility?" et al.