Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Health Literacy Assessment Survey
Confidence Reading Medical Materials
- Very confident
- Somewhat confident
- Not confident
- Prefer not to answer
Understanding Prescription Labels
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Filling Out Health Forms Independently
- Yes
- No
- Not sure
- Not applicable
Understanding Lab Results and Numbers
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Need Help Reading Hospital Materials
- Yes
- No
- Not sure
- Not applicable
Comfort Asking Questions During Visits
- Very comfortable
- Somewhat comfortable
- Not comfortable
Preferred Health Information Format
- Written information
- Conversation with the care team
- Video
- Audio
- Another format
Language Preference for Materials
Awareness of Patient Education Resources
- Yes
- No
- Not sure
- Not applicable
Additional Communication Needs
Health Literacy Assessment Survey template from formisoft.com. formisoft.com/intake-templates/health-literacy-assessment