A patient health readiness quiz that scores knowledge, motivation, access, support and self-management across five dimensions and produces an AI PDF report showing where the clinician should start the conversation.
Quick answer
A patient health readiness quiz scores five domains (knowledge, motivation, access, support, self-management) and produces an AI-written report showing where to focus the first appointment.
Disclaimer: this page and its AI report are for self-reflection and process reference only. They do not constitute medical, psychological, financial, legal or safety advice. Consult a qualified clinician before making care decisions.
Methodology: items are a structural adaptation of widely used clinical frameworks, not an official validated instrument; scores are indicative, not diagnostic.
Two patients get the same diagnosis; one already knows what to do, the other needs everything. This quiz scores knowledge (do you understand the plan), motivation (do you want to change), access (can you get to appointments and medications), support (is someone helping) and self-management (do you have the toolkit) — and writes a plain-language AI report saying what to work on first.
Sample form, AI PDF report and AI consultant — fill the form to unlock all three.
Everything you need to run this template.
From copy to deliverable in four steps.
Copy the form and its scoring, report and branding settings into your FormLM workspace — free.
Adjust fields, options and consent language to match your clinic workflow.
Send the link or QR; every response is captured automatically.
Open the personalized AI PDF report and share it with the patient or the chart.
Pick your role — see how it fits your clinic workflow.
Personalize the first teaching session by readiness, not by guesswork.
Match intervention intensity to readiness stage.
Baseline readiness and re-assess every 8 weeks.
What makes this template work as a professional clinical deliverable.
A preview of real fields patients see — the full version scores each answer 1–5 across dimensions and generates a personalized, printable AI PDF report per respondent.
