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.
* Required
1. Which country are you from?
*
Your answer
2. How old are you?
*
Younger than 30 years old
30 to 49 years old
50 to 60 years old
Older than 60 years old
3. What is your gender?
*
Female
Male
Prefer not to say
4. How many years have you been diagnosed to have Congestive Heart Failure?
*
Less than a year
1 to 5 years
6 to 10 years
More than 10 years
Not sure
5. What are the current ways you and/or your doctors are managing your Congestive Heart Failure condition?
*
Your answer
6. How often do you have to visit your doctor(s)?
*
Once a week
Once every 2 to 4 weeks
Once every 1 to 5 months
Once every 6 to 12 months
Longer than 1 year
7. On average, how long does each examination (e.g. X-ray, blood test, etc.) session in the hospital or clinic take?
*
Shorter than 30 minutes
30 minutes to 59 minutes
1 to 2 hours
Longer than 2 hours
8. What are some of the problems and inconveniences faced by you while receiving treatment in the hospital?
*
Your answer
9. How frequently do you have to take medications at home?
*
More than 3 times daily
1 to 3 times daily
Once every 2 to 3 days
Less than once every week
10. What are some of the problems and inconveniences faced by you when you are managing your Congestive Heart Failure condition at home?
*
Your answer
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?
*
Your answer
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
1
2
3
4
5
Very helpful
For Q12
13. Why do you think it will be helpful/not helpful?
*
Your answer
14. Would you want to buy it?
*
Yes
No
Maybe
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")
*
Your answer
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
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?
*
Your answer
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!)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms