Q01
Message
All templates
7-Day Patient Symptom & Wellbeing Assessment
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
27 questions · ~12 min
Q02
Opinion Scale
Overall, how would you rate your health today?
Scale: 1 – 5
Min:PoorMax:Excellent
Q03
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
Q04
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
Q05
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
Q06
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?
Q07
Dropdown
What is your age group?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65–74
- 75+
- Prefer not to say
Q08
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.
Q09
Long Text
If you selected 'Other' above, please specify which symptom(s) you experienced.
Q10
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
Q11
Opinion Scale
How would you rate your overall sleep quality over the last 7 days?
Scale: 1 – 7
Min:Very poorMax:Very good
Q12
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.
Q13
Multiple Choice
Which of the following best describes your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q14
Opinion Scale
In the last 7 days, how severe was your pain at its worst?
Scale: 1 – 5
Min:Very mildMax:Very severe
Q15
Long Text
If you selected 'Other' above, please specify which side effect(s) you noticed.
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
Long Text
If you selected 'Prefer to self-describe' above, please share your gender identity here.
Q18
Opinion Scale
In the last 7 days, how severe was your fatigue at its worst?
Scale: 1 – 5
Min:Very mildMax:Very severe
Q19
Opinion Scale
Overall, how burdensome were treatment side effects in the last 7 days?
Scale: 1 – 5
Min:Not at all burdensomeMax:Extremely burdensome
Q20
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
Q21
Dropdown
Where do you currently live?
- United States
- Canada
- United Kingdom
- Australia
- European Union
- Other
- Prefer not to say
Q22
Opinion Scale
In the last 7 days, how severe was your shortness of breath at its worst?
Scale: 1 – 5
Min:Very mildMax:Very severe
Q23
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
Q24
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
Q25
Opinion Scale
In the last 7 days, how much did pain interfere with your daily activities?
Scale: 1 – 5
Min:Not at allMax:Extremely
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
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
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Combines structured symptom, pain, fatigue, and shortness-of-breath severity scales with an AI follow-up interview that lets patients elaborate in their own words on how their health affected daily life
- Uses a consistent 7-day recall window across symptoms, treatment side effects, functional limitations, sleep, anxiety, and depression frequency, supporting longitudinal comparison over repeated fielding
- Includes dedicated treatment-status and side-effect burden questions alongside quality-of-life comparison, giving both clinical and PRO-style outcome data in one instrument
- Captures demographic context (age, gender, education, employment, location) for subgroup analysis, with transparent prompts and automated quality scoring on open-text responses
Typeform
Patient Assessment Form TemplateThis is a static, fielding-ready patient assessment form built on Typeform's conversational-style UI. It's a general intake/assessment layout rather than a validated 7-day symptom recall or longitudinal wellbeing instrument. Good for quick clinical intake but not designed for repeated-measures patient monitoring.
What it does well
- Clean, mobile-friendly conversational form format Typeform is known for
- Easy to customize question order and branching logic for basic intake
- Fast to deploy for one-off patient assessments
Where it falls short
- No adaptive AI follow-up interview to probe vague or concerning symptom answers
- No structured 7-day recall design or repeated-measures/longitudinal framing built in
- No published methodology or per-response quality scoring for open-text answers
SurveyMonkey
Patient Satisfaction Survey TemplateThis is a ready-to-use static template, but it's built for post-visit satisfaction and service-experience feedback rather than symptom severity, side-effect burden, or functional status tracking. It's a reasonable comparison point as a patient-facing healthcare survey, though its purpose differs from clinical symptom monitoring.
What it does well
- Purpose-built for capturing patient satisfaction after a visit or encounter
- Backed by SurveyMonkey's broad survey logic and reporting features
- Simple to launch quickly for service-quality feedback
Where it falls short
- Focused on satisfaction/experience, not symptom severity, side effects, or 7-day functional recall
- No adaptive AI interview or voice interview option to explore patient narratives
- No transparent prompt methodology or automated per-response quality scoring
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.