Questionnaire for Congestive Heart Failure Patients
This questionnaire is meant for patients who have been diagnosed to have Congestive Heart Failure and are seeking consultations or examinations or treatment on their Congestive Heart Failure condition. We have already collected more than 300 samples from more than 100 patients and are in the midst of collecting more. Your help in providing us feedback by filling in this form is important and will help develop a new way of helping Congestive Heart Failure patients better manage their Heart Failure conditions.
Sign in to Google to save your progress. Learn more
1. Which country are you from? *
2. How old are you? *
3. What is your gender? *
4. How many years have you been diagnosed to have Congestive Heart Failure? *
5. What are the current ways you and/or your doctors are managing your Congestive Heart Failure condition? *
6. How often do you have to visit your doctor(s)? *
7. On average, how long does each examination (e.g. X-ray, blood test, etc.) session in the hospital or clinic take? *
8. What are some of the problems and inconveniences faced by you while receiving treatment in the hospital? *
9. How frequently do you have to take medications at home? *
10. What are some of the problems and inconveniences faced by you when you are managing your Congestive Heart Failure condition at home? *
11. What do you wish to add to your current home monitoring practice (as advised by your doctor) to make yourself feel that you’re in better control of your illness? *
12. Can you rate the heart failure monitor (see image below) on the usefulness on the scale of 1 to 5 (5 being very helpful to 1 not helpful at all)? *
Not helpful at all
Very helpful
For Q12
13. Why do you think it will be helpful/not helpful? *
14. Would you want to buy it? *
15. If you want to buy the device, what is the maximum amount you’re prepared to pay for it? (Skip this question if your answer for the Question 14 is “ No") *
16. Please rate the following features to be built into the design of the heart failure monitor by choosing the most relevant option: *
Must have
Good to have
Optional
Not useful
Features
Small in size
Lightweight
Ease of use
Fast measurement time
Can be used by anyone
Can be used anywhere
Wireless
17. What are some additional features or information that is not listed in the Table above in Q16 but you would like to have? *
18. Would you like to receive more information and news on our product? (If you would like to, please leave your contact details (e.g. Email/Phone number/Social Media account) below and we will get in touch with you!)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms