Patient Wellbeing Survey Template: Symptoms & Side Effects
Patient wellbeing survey template to track symptoms, side effects, and quality of life over the past 7 days. Ready to use. Customize, share, and analyze fast.
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
24
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
Rating
Overall, how would you rate your health today?
Scale: 11 (star)
Min: PoorMax: Excellent
Q2
Multiple Choice
In the last 7 days, which 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
Q3
Short Text
If you selected Other, please specify (optional).
Max 100 chars
Q4
Matrix
In the last 7 days, how severe were the following? Select “None” if not experienced.
Rows
None
Very mild
Mild
Moderate
Severe
Pain
•
•
•
•
•
Fatigue or tiredness
•
•
•
•
•
Nausea
•
•
•
•
•
Shortness of breath
•
•
•
•
•
Sleep problems
•
•
•
•
•
Anxiety or stress
•
•
•
•
•
Q5
Opinion Scale
In the last 7 days, how much did pain interfere with your daily activities?
Range: 1 – 10
Min: Not at allMax: Extremely
Q6
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
Q7
Multiple Choice
Are you currently receiving treatment related to your condition?
Yes, currently receiving treatment
No, completed treatment in the last 3 months
No, no treatment in the last 3 months
Q8
Multiple Choice
In the last 7 days, which 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
Q9
Short Text
If you selected Other side effects, please specify (optional).
Max 100 chars
Q10
Rating
Overall, how burdensome were treatment side effects in the last 7 days? (If none, select Not burdensome.)
Scale: 11 (star)
Min: Not burdensomeMax: Extremely burdensome
Q11
Numeric
During the last 7 days, on how many days were you limited in your usual activities?
Accepts a numeric value
Whole numbers only
Q12
Opinion Scale
Overall sleep quality in the last 7 days:
Range: 1 – 10
Min: Very poorMax: Very good
Q13
Matrix
In the last 7 days, how often did you experience the following?
Rows
Never
Rarely
Sometimes
Often
Always
Feeling nervous or anxious
•
•
•
•
•
Feeling down or depressed
•
•
•
•
•
Feeling calm or relaxed
•
•
•
•
•
Able to concentrate on what you were doing
•
•
•
•
•
Feeling socially connected
•
•
•
•
•
Q14
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
Q15
Multiple Choice
Attention check: To confirm attention, please select “Sometimes.”
Never
Rarely
Sometimes
Often
Always
Q16
Multiple Choice
What is your age group?
18–24
25–34
35–44
45–54
55–64
65–74
75+
Prefer not to say
Q17
Multiple Choice
Which of the following best describes your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Q18
Short Text
If you prefer to self-describe your gender, please enter it here (optional).
Max 100 chars
Q19
Dropdown
Where do you currently live?
United States
Canada
United Kingdom
Australia
European Union
Other
Prefer not to say
Q20
Multiple Choice
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
Q21
Multiple Choice
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
Q22
Long Text
Is there anything else you would like to share about your health, treatment, or daily life?
Max 600 chars
Q23
AI Interview
AI Interview: 2 Follow-up Questions on your recent health and daily life
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q24
Chat Message
Thank you for completing this survey. Your feedback is appreciated.
Frequently Asked Questions
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