Health-Resiliency-Stress Questionnaire (HRSQ)
Copyright, all rights reserved (3/2019)

Filling out this questionnaire may give your provider helpful information about your health and wellness. This form usually takes about 3 - 7 minutes to complete, but don't worry if you need some extra time. Your participation is very important to your health care provider. Your answers are also important to better understand how stress and resiliency affect health.

If at any point you do not want to complete this questionnaire, simply exit-out and your answers will not be recorded. If you do complete this form, your information will automatically be sent to your health care provider's email. (You will be asked for that in a question below.) Your answers will be recorded in a large database. No information will be recorded about who you are or that can identify you. The code from your doctor or therapist will be scrubbed from the database but will appear within the email and the electronic attachment that will also contain your answers. The ip address will also be scrubbed. your provider's email will be recorded in the database.

The answers you provide will be pooled with all other data and will become part of a research effort to validate the HRSQ and future studies to better understand the utility of the HRSQ. The pooled database will not be sold, bartered, or shared. No identifying information will be solicited or requested of you. This is an approved study through the Institutional Review Board of the University of Utah.


Please fill this out as completely and as best as you can. Thank you for participating!
Your doctor's or therapist's email address *
Code from your doctor or therapist *
Age *
Gender *
Zip Code (enter 00000 if you do not have a permanent address) *
Next
Never submit passwords through Google Forms.
This form was created inside of Sovegna. Report Abuse