Chronic Disease Coaching Outcome Survey
Help us evaluate the effectiveness of your chronic disease coaching experience. Your responses are confidential and will guide program improvements.
Participant Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
What is your primary chronic condition?
*
Please Select
Diabetes
Hypertension
Heart Disease
Chronic Respiratory Disease
Cancer
Other
How long have you been participating in the coaching program?
*
Please Select
Less than 1 month
1-3 months
3-6 months
More than 6 months
Please rate the following aspects before and after coaching:
*
Rows
Before Coaching
After Coaching
Physical activity level
Poor
Fair
Good
Very Good
Excellent
Poor
Fair
Good
Very Good
Excellent
Healthy eating habits
Poor
Fair
Good
Very Good
Excellent
Poor
Fair
Good
Very Good
Excellent
Medication adherence
Poor
Fair
Good
Very Good
Excellent
Poor
Fair
Good
Very Good
Excellent
Stress management
Poor
Fair
Good
Very Good
Excellent
Poor
Fair
Good
Very Good
Excellent
Overall health
Poor
Fair
Good
Very Good
Excellent
Poor
Fair
Good
Very Good
Excellent
How satisfied are you with the coaching program overall?
*
1
2
3
4
5
Which of the following benefits have you experienced from coaching? (Select all that apply)
*
Improved understanding of my condition
Better self-management skills
Increased motivation
Reduced symptoms
Improved quality of life
Other
Would you recommend this coaching program to others?
*
Yes
No
Not Sure
Please provide any additional comments or suggestions about the coaching program.
Submit Survey
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