A patient-reported outcome instrument tracking symptoms, treatment side effects, functional limitations, and quality of life over a 7-day recall period. Suitable for clinical research, treatment monitoring, and longitudinal patient wellbeing studies.
What's Included
AI-Powered Questions
Intelligent follow-up questions based on responses
Automated Analysis
Real-time sentiment and insight detection
Smart Distribution
Target the right audience automatically
Detailed Reports
Comprehensive insights and recommendations
Template Overview
27
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Chat Message
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 5–8 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.
Q2
Opinion Scale
Overall, how would you rate your health today?
Range: 1 – 5
Min: PoorMid: NeutralMax: Excellent
Q3
Multiple Choice
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
Q4
Long Text
If you selected 'Other' above, please specify which symptom(s) you experienced.
Max chars
Q5
Opinion Scale
In the last 7 days, how severe was your pain at its worst?
Range: 1 – 5
Min: Very mildMid: NeutralMax: Very severe
Q6
Opinion Scale
In the last 7 days, how severe was your fatigue at its worst?
Range: 1 – 5
Min: Very mildMid: NeutralMax: Very severe
Q7
Opinion Scale
In the last 7 days, how severe was your shortness of breath at its worst?
Range: 1 – 5
Min: Very mildMid: NeutralMax: Very severe
Q8
Opinion Scale
In the last 7 days, how much did pain interfere with your daily activities?
Range: 1 – 5
Min: Not at allMid: NeutralMax: Extremely
Q9
Dropdown
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
Q10
Multiple Choice
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
Q11
Multiple Choice
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
Q12
Long Text
If you selected 'Other' above, please specify which side effect(s) you noticed.
Max chars
Q13
Opinion Scale
Overall, how burdensome were treatment side effects in the last 7 days?
Range: 1 – 5
Min: Not at all burdensomeMid: NeutralMax: Extremely burdensome
Q14
Dropdown
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
Q15
Opinion Scale
How would you rate your overall sleep quality over the last 7 days?
Range: 1 – 7
Min: Very poorMid: NeutralMax: Very good
Q16
Dropdown
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
Q17
Dropdown
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
Q18
Multiple Choice
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
Q19
Long Text
Based on your responses in this survey, is there anything else you would like to share about your health, symptoms, treatment, or daily life?
Max chars
Q20
AI Interview
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.
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Reference questions: 5
Q21
Dropdown
What is your age group?
18–24
25–34
35–44
45–54
55–64
65–74
75+
Prefer not to say
Q22
Multiple Choice
Which of the following best describes your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Q23
Long Text
If you selected 'Prefer to self-describe' above, please share your gender identity here.
Max chars
Q24
Dropdown
Where do you currently live?
United States
Canada
United Kingdom
Australia
European Union
Other
Prefer not to say
Q25
Dropdown
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
Q26
Dropdown
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
Q27
Chat Message
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.
Frequently Asked Questions
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