Physician Burnout Questionnaire
Please complete this questionnaire to help assess burnout symptoms and contributing factors among physicians. Your responses are confidential and will be used to improve workplace wellbeing.
Full Name (optional)
First Name
Last Name
Department / Specialty
*
Years in Practice
*
On average, how many hours do you work per week?
*
Please indicate your level of agreement with the following statements:
*
Rows
Never
Rarely
Sometimes
Often
Always
I feel emotionally drained from my work.
1
2
3
4
5
I feel fatigued when I get up in the morning and have to face another day on the job.
6
7
8
9
10
I feel I am positively influencing other people’s lives through my work.
11
12
13
14
15
I have become more callous toward people since I took this job.
16
17
18
19
20
I feel I am accomplishing many worthwhile things in my job.
21
22
23
24
25
How would you rate your overall level of burnout?
*
No burnout
1
2
3
4
5
6
7
8
9
Severe burnout
10
1 is No burnout, 10 is Severe burnout
How satisfied are you with your current work-life balance?
*
1
2
3
4
5
Which of the following factors contribute most to your feelings of burnout? (Select all that apply)
*
Long working hours
High patient load
Administrative burden
Lack of support
Inadequate resources
Personal life stressors
Other
Have you considered leaving your current position due to burnout?
*
Yes
No
Not sure
What resources or changes would help reduce your burnout?
Would you like to be contacted for follow-up or support? If yes, please provide your email address below.
example@example.com
Submit Questionnaire
Should be Empty: