Patient/Family Forms

LivHealth Patient Quality of life Assessment

Please answer this questionnaire to the best of your ability and as honestly as possible.
This will help us to access your current quality of life so that
we can work to heal you as best as possible.

I have a lack of energy

Not at allA littleSometimesOftenAlways

I have nausea

Not at allA littleSometimesOftenAlways

I have pain

Not at allA littleSometimesOftenAlways

I am constipated

Not at allA littleSometimesOftenAlways

I have been short of breath

Not at allA littleSometimesOftenAlways

I am sleeping well

Not at allA littleSometimesOftenAlways

I feel sad

Not at allA littleSometimesOftenAlways

I worry that my condition will get worse

Not at allA littleSometimesOftenAlways

I feel like a burden to my family

Not at allA littleSometimesOftenAlways

I feel hopeful

Not at allA littleSometimesOftenAlways

I am able to enjoy life

Not at allA littleSometimesOftenAlways

I get emotional support from my family

Not at allA littleSometimesOftenAlways

I am able to openly discuss my concern with the people closest to me

Not at allA littleSometimesOftenAlways

I am content with my quality of life right now

Not at allA littleSometimesOftenAlways

LivHealth Caregiver Questionnaire

Caregivers are often so concerned with caring for their relative’s needs that they
lose sight of their own well-being. Please take just a moment
to answer the following questions.

During the past week or so, I have …

Had trouble keeping my mind on what I was doing

YesNo

Felt that i couldn't leave my relative alone

YesNo

Had difficulty making decisions

YesNo

Felt completely overwhelmed

YesNo

Felt useful and needed

YesNo

Felt lonely

YesNo

Been upset that my relative has changed so much from his/her former self

YesNo

Felt a loss of privacy and/or personal time

YesNo

Been edge or irritable

YesNo

Had sleep disturbed because of caring for my relative

YesNo

Had a crying spell(s)

YesNo

Felt strained between work and family responsibilities

YesNo

Had back pain

YesNo

Felt ill(headaches, stomach problem or common cold)

YesNo

Been satisfied with the support my family has given me

YesNo

Found my relative's living situation to be inconvenient or a barrier to care

YesNo

On a scale of 1 to 10, with 1 being "not stressful" to 10 being "extremely stressful". please rate your current level of stress

On a scale of 1 to 10, with 1 being "very healthy" to 10 being "very ill," please rate your current health compared to what it was this time last year

Comments

Patient/Family Satisfaction Survey

Please answer the following questions based on your experience
with LivHealth. Mark your answers in the boxes provided below.
This information would be confidential

What was the ease of making an appointment visit?

PoorFairGoodVery GoodExcellent

How easy was it to contact our doctor out of hours?

PoorFairGoodVery GoodExcellent

How long did it take for someone to respond when called with an urgent problem?

PoorFairGoodVery GoodExcellent

Has this method of health care delivery provided a better experience than usual clinic visit?

PoorFairGoodVery GoodExcellent

Did we provide adequate emotional support during this time?

PoorFairGoodVery GoodExcellent

Do you feel that this service benefited your caregiver?

PoorFairGoodVery GoodExcellent

How would you rate the clarity and completeness of information and explanations given, to help manage your condition?

PoorFairGoodVery GoodExcellent

How competent did you feel your practitioner was?

PoorFairGoodVery GoodExcellent

Based on this experience, how do you rate your overall satisfaction with this service?

PoorFairGoodVery GoodExcellent

How likely are you to recommend this service to your friend/family?

PoorFairGoodVery GoodExcellent

What aspects of our service were you most impressed with?

PoorFairGoodVery GoodExcellent

What aspects of our service can be improved?

PoorFairGoodVery GoodExcellent

Thank you for your valuable feedback, this confidential information
would be used only in an effort to improve care services.

Request
Consultation Tab

A LivHealth representative will
contact you shortly.

Patient/Family Forms

LivHealth Patient Quality of life Assessment

LivHealth Caregiver Questionnaire

Patient/Family Satisfaction Survey

Request Consultation Tab

Request
Consultation Tab