FPM Toolbox

Patient Surveys/Questionnaires

Chart Prep Questionnaire

A patient questionnaire that helps nursing staff ensure that recent clinical reports and data are collected in the patient's chart
Download Format: Word
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Diabetes Assessment Form

An annual questionnaire that helps patients with diabetes think about their health care goals and identify areas in which they may need assistance
Download Format: PDF
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Health Confidence Measure

A tool for assessing patients' confidence in their ability to control and manage their health problems
Download Format: PDF
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Health Risk Assessment/Medicare Wellness Checkup

A health risk assessment Medicare patients can complete as part of their annual wellness visits
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New Patient Questionnaire

A list of basic health care questions for new patients designed to gather the patient's history, initiate a dialogue for the exam, and help the patient feel more comfortable with a new physician
Download Format: PDF
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Patient Phone-System Survey

A survey that asks patients to evaluate the efficiency of a practice's phone system
Download Format: PDF
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Patient Satisfaction Survey

A sample survey practices can use to measure patient satisfaction
Download Format: PDF
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Pre-Visit Questionnaire

A list of questions the patient completes on paper in the waiting room or through an online patient portal from home
Download Format: PDF
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Problem-Solving Worksheet

A worksheet to help patients set goals that will help them tackle their health problems
Tool as published
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Today's Visit Checklist

A brief checklist for patients that helps them focus their goals for the current visit
Download Format: Word
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