Q01
Long Text
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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 · ~4 min
Q02
Long Text
Overall, how would you rate your health today?
Q03
Multiple Choice
In the last 7 days, which of the following symptoms did you experience? (Select all that apply)
Q04
Multiple Choice
Which of the following best describes your current treatment status?
Q05
Long Text
During the last 7 days, on how many days were you limited in your usual activities?
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
Long Text
What is your age group?
Q08
Long Text
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)
Q11
Long Text
How would you rate your overall sleep quality over the last 7 days?
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?
Q14
Long Text
In the last 7 days, how severe was your pain at its worst?
Q15
Long Text
If you selected 'Other' above, please specify which side effect(s) you noticed.
Q16
Long Text
In the last 7 days, how often did you feel anxious or worried?
Q17
Long Text
If you selected 'Prefer to self-describe' above, please share your gender identity here.
Q18
Long Text
In the last 7 days, how severe was your fatigue at its worst?
Q19
Long Text
Overall, how burdensome were treatment side effects in the last 7 days?
Q20
Long Text
In the last 7 days, how often did you feel down or depressed?
Q21
Long Text
Where do you currently live?
Q22
Long Text
In the last 7 days, how severe was your shortness of breath at its worst?
Q23
Multiple Choice
Compared with one month ago, how is your overall quality of life?
Q24
Long Text
What is the highest level of education you have completed?
Q25
Long Text
In the last 7 days, how much did pain interfere with your daily activities?
Q26
Long Text
What is your current employment status?
Q27
Long Text
In the last 7 days, how often did you feel unusually tired?
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.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.