Surgery Prehabilitation Survey Form
Help us understand your needs and readiness for surgery prehabilitation.
How would you describe your current physical activity level?
*
Very active
Moderately active
Somewhat active
Not active
How confident do you feel about preparing for your upcoming surgery?
*
1
2
3
4
5
Which of the following prehabilitation activities have you participated in? (Select all that apply)
Exercise program
Nutrition counseling
Smoking cessation support
Mental wellness sessions
Other
Please rate your agreement with the following statements about surgery prehabilitation.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I understand the purpose of prehabilitation.
1
2
3
4
5
I believe prehabilitation will improve my recovery.
6
7
8
9
10
I have access to resources for prehabilitation.
11
12
13
14
15
I feel supported by my healthcare team.
16
17
18
19
20
Do you have any dietary restrictions or preferences?
No
Yes
Prefer not to say
How would you rate your overall nutrition in the past month?
1
2
3
4
5
What is your biggest concern regarding your upcoming surgery?
Who will be your main support person during your surgery and recovery?
How likely are you to follow a recommended prehabilitation program?
*
Not at all likely
1
2
3
4
Extremely likely
5
1 is Not at all likely, 5 is Extremely likely
Please share any additional comments or suggestions about your prehabilitation experience.
Submit Survey
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