Sickle Cell Impact Survey Form
Please complete this survey to help us understand the everyday impact of sickle cell disease. Your responses are confidential and will be used for research and support improvement.
How often do you experience pain episodes related to sickle cell disease?
*
Daily
Weekly
Monthly
Rarely
How would you rate the impact of sickle cell disease on your daily activities?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
In the past month, how many days have you missed school or work due to sickle cell disease?
None
1-2 days
3-5 days
More than 5 days
Please rate your overall quality of life.
*
1
2
3
4
5
How often do you feel supported by friends or family?
Always
Often
Sometimes
Rarely/Never
How would you describe your access to healthcare for managing sickle cell disease?
Excellent
Good
Fair
Poor
Please indicate how much you agree with the following statements about your experience.
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel informed about my condition.
1
2
3
4
5
I am able to manage my symptoms effectively.
6
7
8
9
10
I have access to the support I need.
11
12
13
14
15
What is your age group?
Please Select
Under 18
18-24
25-34
35-44
45-54
55 or older
Please share any additional comments about your experience with sickle cell disease.
Submit Survey
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