FPM Toolbox

Patient Surveys/Questionnaires

Adult Health 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
Tool as published
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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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Genogram Template

A genogram template for patients' family relationships and medical history that can provide a quick and useful context in which to evaluate an individual's health risks
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-Appointment Questionnaire

A questionnaire to help you understand the patient's primary agenda for the visit
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
Source Article

Survey of Patient Internet/E-mail Capability and Interest

A survey to identify patients' ability to communicate with your practice via the Internet
Download Format : PDF
Source Article

Today's Visit Checklist

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

Wellness Care - Medicare Checkup

A health risk assessment Medicare patients can complete as part of their annual wellness visits
Download Format : PDF
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