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Patient Health Literacy & Plain Language Assessment
Measures how well patients understand medical information across print, digital, and telehealth channels. Designed for healthcare communicators seeking to identify comprehension barriers and optimize plain-language materials.
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Patient Health Literacy & Plain Language Assessment
Thank you for taking part in this survey about understanding health information. Your responses are voluntary and confidential — you may stop at any time. There are no right or wrong answers; we are interested in your honest opinions. Your answers will be combined with those of other participants and reported only in aggregate. This survey takes approximately 8 minutes. Please think about your most recent clinic, hospital, or telehealth visit in the last 12 months as you answer.
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Sample questions
A preview of what’s in the template. Every question is editable before you launch.
23 questions · ~11 min
Q01
Multiple Choice
In the last 12 months, have you had at least one clinic, hospital, or telehealth visit?
- Yes
- No
Q02
Multiple Choice
Which language do you prefer for health information?
- English
- Spanish
- Chinese
- Vietnamese
- Arabic
- Other (please specify)
Q03
Opinion Scale
How confident are you in your ability to fill out medical forms by yourself?
Scale: 1 – 7
Min:Not at all confidentMax:Extremely confident
Q04
Opinion Scale
Overall, how easy or difficult was it to understand the written health information you received in the last 12 months?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q05
Multiple Choice
In the last 12 months, which types of health information were difficult for you to understand? (Select all that apply)
- Appointment reminders
- Consent forms
- Discharge or visit instructions
- Bills and statements
- Lab or test results
- Medication labels or instructions
- Insurance or coverage documents
- None of these were difficult
Q06
Long Text
Please list any medical words, phrases, or sections of documents that were confusing to you in the last 12 months.
Q07
Multiple Choice
In the last 12 months, did you use a patient portal or app to view your health information?
- Yes
- No
Q08
Opinion Scale
How clear was the health information displayed on the patient portal or app?
Scale: 1 – 7
Min:Not at all clearMax:Extremely clear
Q09
Multiple Choice
In the last 12 months, did you have any telehealth (video or phone) visits?
- Yes
- No
Q10
Opinion Scale
During your telehealth visits, how often did you fully understand what to do after the visit ended?
Scale: 1 – 7
Min:NeverMax:Always
Q11
Multiple Choice
Which of the following do you currently have access to? (Select all that apply)
- Smartphone
- Computer or tablet
- Home internet or Wi-Fi
- Screen reader or text-to-speech software
- None of these
Q12
Multiple Choice
Which of the following would help you when reading health information? (Select all that apply)
- Larger text or print
- Audio versions or text-to-speech
- Captions on videos
- High-contrast colors
- None of these
Q13
Ranking
Please rank the following from most to least preferred for receiving important health instructions or results.
- Printed handout
- Text or SMS
- Patient portal or app
- Phone call or voicemail
- Short video
- In-person demonstration
Drag to rank
Q14
Multiple Choice
Which of the following formats help you understand health information best? (Select all that apply)
- Bullet-point lists
- Step-by-step checklists
- Pictures or diagrams
- Simple real-life examples
- Medical term with plain-language definition
- Translated materials in my language
- Large print
Q15
Multiple Choice
Which of the following materials would you most like to have available in your preferred language? (Select all that apply)
- Appointment reminders
- Consent forms
- Visit or discharge instructions
- Bills and statements
- Lab or test results
- Medication labels
Q16
Ranking
If we could simplify only a few areas of health information, which would help you the most? Please rank from most to least important.
- Medication instructions
- Test and lab results
- Insurance and billing
- Consent and legal forms
- Discharge and follow-up instructions
- Appointment scheduling
Drag to rank
Q17
Long Text
Based on your responses in this survey, is there anything else that would make health information easier for you to understand?
Q18
AI Interview
We'd like to learn a bit more about your experience. An AI interviewer will ask you a couple of follow-up questions about understanding health information.
Q19
Dropdown
What is your age?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65–74
- 75 or older
- Prefer not to say
Q20
Multiple Choice
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q21
Dropdown
What is the highest level of education you have completed?
- Less than high school
- High school or GED
- Some college or trade school
- Associate degree
- Bachelor's degree
- Graduate or professional degree
- Prefer not to say
Q22
Dropdown
What is your current employment status?
- Full-time
- Part-time
- Self-employed
- Homemaker or caregiver
- Student
- Retired
- Not currently employed
- Prefer not to say
Q23
Dropdown
In which country do you currently live?
- United States
- United Kingdom
- Canada
- Australia
- Other
- Prefer not to say
Message
Thank you for participating. Your feedback helps us make health information clearer and easier to use for everyone.
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 comprehension checks (opinion scales on form-filling confidence, understanding written materials, telehealth follow-up instructions) with an open-text question asking patients to name specific confusing words or document sections
- Segments understanding across print, patient portal/app, and telehealth channels separately, rather than treating 'health information' as one undifferentiated category
- Uses ranking questions to prioritize which formats and topics patients most want simplified, giving healthcare communicators an actionable priority list, not just satisfaction scores
- Closes with an AI follow-up interview that can probe deeper into a patient's specific comprehension barriers, something no static form in this space offers
Jotform
600+ Healthcare Assessment FormsThis is a broad category/index page listing hundreds of healthcare-related form templates (intake, consent, screening, satisfaction, etc.), not a dedicated health literacy or plain-language comprehension assessment. A researcher would need to search within the library and likely build a comprehension-specific survey from scratch or heavily customize an existing form. Useful as a starting point for generic healthcare data collection, not for measuring patient understanding of medical language.
What it does well
- Very large template library covering many healthcare use cases
- Drag-and-drop form builder likely allows customization to add literacy-related questions
- Established platform with broad healthcare-sector adoption
Where it falls short
- No template specifically designed to measure health literacy or plain-language comprehension across print, portal, and telehealth channels
- Static form fields only — no adaptive AI follow-up questioning to probe why a patient found information confusing
- No built-in automated quality scoring or transparent prompt methodology for interpreting comprehension gaps
Frequently asked questions
What questions are in the “Patient Health Literacy & Plain Language Assessment” template?
The template includes 23 ready-to-use questions, starting with: “In the last 12 months, have you had at least one clinic, hospital, or telehealth visit?” · “Which language do you prefer for health information?” · “How confident are you in your ability to fill out medical forms by yourself?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 23 questions in about 11 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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