FPM Toolbox
Patient Surveys/Questionnaires
Download sample patient satisfaction surveys and other questionnaires.
Alcohol Prescreening Questionnaire |
A series of questions to be included in a patient previsit questionnaire designed to screen for potential risky drinking behavior |
Download Format: PDF |
Source Article |
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: PDF |
Source Article |
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 |
Source Article |
HCA Patient Education Form |
A checklist to help prepare patients for advance care planning conversations, starting with selecting a health care agent |
Tool as published |
Source Article |
Health Confidence Measure |
A tool for assessing patients' confidence in their ability to control and manage their health problems |
Download Format: PDF |
Source Article |
Health Risk Assessment/Medicare Wellness Checkup |
A health risk assessment Medicare patients can complete as part of their annual wellness visits |
Download Format: PDF |
Source Article |
Patient Satisfaction Survey |
A sample survey practices can use to measure patient satisfaction |
Download Format: PDF |
Source Article |
Phone System Survey |
A survey that asks patients to evaluate the efficiency of a practice's phone system |
Download Format: PDF |
Source Article |
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 |
Source Article |
Social Needs: Patient Questionnaire |
An 11-question tool to help practices screen for social determinants of health |
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: PDF |
Source Article |
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