7-Day Patient Symptom & Wellbeing Assessment

Welcome to the Patient Wellbeing Survey. This survey asks about your health, symptoms, treatment, and daily life over the past 7 days. It takes approximately 12 minutes to complete. Your participation is entirely voluntary and you may stop at any time. There are no right or wrong answers — we are interested in your honest experiences. All responses are confidential and will be reported only in aggregate. By continuing, you indicate your consent to participate.

Overall, how would you rate your health today?

In the last 7 days, which of the following symptoms did you experience? (Select all that apply)

• Pain
• Fatigue or tiredness
• Shortness of breath
• Nausea
• Dizziness
• Sleep problems
• Anxiety or stress
• Fever or chills
• None of the above
• Other

If you selected 'Other' above, please specify which symptom(s) you experienced.

In the last 7 days, how severe was your pain at its worst?

In the last 7 days, how severe was your fatigue at its worst?

In the last 7 days, how severe was your shortness of breath at its worst?

In the last 7 days, how much did pain interfere with your daily activities?

In the last 7 days, how often did you feel unusually tired?

• Never
• Rarely (1–2 days)
• Sometimes (3–4 days)
• Often (5–6 days)
• Every day

Which of the following best describes your current treatment status?

• Currently receiving treatment
• Completed treatment in the last 3 months
• No treatment in the last 3 months

In the last 7 days, which of the following treatment side effects did you notice, if any? (Select all that apply)

• Nausea or upset stomach
• Headache
• Drowsiness
• Dry mouth
• Dizziness
• Skin rash or irritation
• Injection site pain
• Mood changes
• None of the above
• Other

If you selected 'Other' above, please specify which side effect(s) you noticed.

Overall, how burdensome were treatment side effects in the last 7 days?

During the last 7 days, on how many days were you limited in your usual activities?

• 0 days
• 1 day
• 2 days
• 3 days
• 4 days
• 5 days
• 6 days
• 7 days

How would you rate your overall sleep quality over the last 7 days?

In the last 7 days, how often did you feel anxious or worried?

• Never
• Rarely (1–2 days)
• Sometimes (3–4 days)
• Often (5–6 days)
• Every day

In the last 7 days, how often did you feel down or depressed?

• Never
• Rarely (1–2 days)
• Sometimes (3–4 days)
• Often (5–6 days)
• Every day

Compared with one month ago, how is your overall quality of life?

• Much worse
• A little worse
• About the same
• A little better
• Much better

Based on your responses in this survey, is there anything else you would like to share about your health, symptoms, treatment, or daily life?

We'd like to learn a bit more about how your health has affected your daily life recently. A short follow-up conversation will ask you a couple of questions.

What is your age group?

• 18–24
• 25–34
• 35–44
• 45–54
• 55–64
• 65–74
• 75+
• Prefer not to say

Which of the following best describes your gender?

• Woman
• Man
• Non-binary
• Prefer to self-describe
• Prefer not to say

If you selected 'Prefer to self-describe' above, please share your gender identity here.

Where do you currently live?

• United States
• Canada
• United Kingdom
• Australia
• European Union
• Other
• Prefer not to say

What is the highest level of education you have completed?

• Less than high school
• High school or equivalent
• Some college or technical training
• Bachelor's degree
• Graduate or professional degree
• Prefer not to say

What is your current employment status?

• Employed full-time
• Employed part-time
• Self-employed
• Unemployed
• Student
• Homemaker or caregiver
• Retired
• Unable to work
• Prefer not to say

Thank you for completing this survey. Your responses are valuable and will help improve care and support for patients. If you have any concerns about your health or symptoms, please reach out to your care team.