Is this the Patient Activation Measure?

No. It is an original feedback questionnaire about one conversation. It does not reproduce a validated activation instrument or generate a clinical score.

What if no treatment decision was discussed?

Keep the option stating that no decision was needed. Do not turn it into a negative rating.

Can patients use it to ask for medical help?

This feedback version is not a care-request channel. Show the provider's actual contact route separately and explain that the public example is not monitored by a care team.

Before the conversation, did you have questions you wanted to ask?

Yes, and I had them in mind or written down

Yes, but I had not organized them

How much opportunity did you have to ask the questions you wanted to ask?

Enough opportunity for all of them

Too little opportunity to ask any

I did not have questions to ask

If options for a decision were discussed, how clear was the explanation?

I did not need to make a decision

How much opportunity did you have to explain what mattered to you?

I did not want to discuss preferences

What most limited your participation?

Communication or accessibility needs

Feeling uncomfortable speaking up

Nothing limited my participation

Patient Participation Survey Template

This patient participation survey helps care teams understand whether adults could ask questions, discuss preferences and follow the explanation of next steps during one appointment. Its seven optional questions focus on the conversation rather than an overall satisfaction rating.

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Healthcare and Hospital Survey Templates

Healthcare CAHPS® Visit v2.0 Survey Template Healthcare When a patient chooses to enter your hospital, the quality of the treatment they are going to receive is the most important thing. To reach a high quality in the treatment, several aspects have to be taken into consideration. Everything from the first contact with the hospital staff, to the behavior of the doctor the patient visited.
Healthcare CAHPS® 12 Month v2.0 Adult Survey Template Healthcare Every smart hospital that cares for their patients’ satisfaction with the care received by them works hard on understanding their patients’ needs. It is done by asking them for their feedback, opinions, and ideas throughout their healthcare experience.
Healthcare CAHPS® Health Plan v4.0 Survey Template Healthcare Understanding how patients perceive their health plans is critical for every forward-thinking hospital, clinic, or healthcare network. With rising expectations and increasing competition, it’s no longer enough to simply offer care — patients expect transparency, convenience, and personalized service.
21-Day Wellness Challenge Survey Template Healthcare Use this 21-day wellness challenge survey template to learn how participants experienced your program and what made it easier or harder to take part. The eight questions cover participation, instructions, support, and suggestions for the next challenge. You can adapt the questionnaire in SurveyLegend without asking people to share weight, diagnoses, or other private health details.
Dental Patient Experience Survey Template Healthcare Patients can explain how a visit felt without being asked to judge treatment quality. Focus on arrangements, communication, and opportunities to ask questions. Keep clinical questions and individual concerns in the practice’s established patient-contact process.
Autistic Adult Accessibility Survey Template Healthcare A venue can offer interesting activities while leaving visitors uncertain about crowds, noise or where to take a break. Adapt this SurveyLegend questionnaire with autistic adults, then ask about one named place and a recent experience. The purpose is to improve access, not assess a person's autism.
Caregiver Support Intake Form Template Healthcare Caregiving arrangements differ from one household to the next. A short intake can make the first conversation more useful without asking for the care recipient’s medical history. Adapt this SurveyLegend questionnaire to the resources your service actually provides.
Group Therapy Interest Survey Template Healthcare This group therapy interest survey helps a counseling service plan clear information and practical access to a proposed adult group. It asks about preferences without collecting symptoms or personal histories. Build the questionnaire in SurveyLegend and keep it separate from clinical assessment, consent and enrollment.
Health Insurance Choice Support Survey Template Healthcare Someone can understand the monthly price and still struggle to compare coverage details. Ask about the part of the choice they are trying to make. Use SurveyLegend to prepare a feedback questionnaire about that process without collecting policy numbers, medical history or application documents.
Healthcare Expenses Survey Template Healthcare A patient may receive an estimate but still not know whom to ask about it. Separate receiving information from understanding it and reaching the right contact. Create this questionnaire in SurveyLegend to examine that part of the service experience.
Pharmacy Service Satisfaction Survey Template Healthcare A customer may leave with what they came for yet still have questions about the process. This SurveyLegend questionnaire separates the experience of waiting and finding help from whether service information was understandable.
Sleeping Habits Survey Template Healthcare Not everyone sleeps at night or follows the same schedule each day. This questionnaire uses a main sleep period so adults with daytime or changing sleep schedules can answer. Use it for a short, voluntary snapshot before planning a discussion or a more detailed study. A recalled week cannot show exactly what happened each day.
Smoking Support Preferences Survey Template Healthcare This smoking support preferences survey gives community teams seven optional questions for planning an offer people can actually access. It does not score dependence or prescribe a quit plan. Build the questionnaire in SurveyLegend, explain how responses will be used and keep participation separate from eligibility for other services.

Patient Participation Survey Template

When to Use This Template

7 Patient Participation Survey Questions

A little feedback. A clearer picture.