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Preliminary Information
Hello! Welcome to the Stepwise Patient Advocacy questionnaire to introduce yourself prior to our first encounter.
Note: All information provided here is protected and will not be shared with any other person or entity.
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1.
Contact Information
(Required.)
Name (first/last)
Email address
Phone number
City/State
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2.
Are you the patient, or are you calling on behalf of someone?
(Required.)
I am the patient
I am calling on behalf of someone else
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3.
If someone else, what is your relationship to that person?
(Required.)
Family
Friend
Legal representative
Other (please specify)
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4.
What is the primary issue you’re seeking help with? Please select from the following:
(Required.)
Finding a physician
Get a definite diagnosis
Get a second opinion
Understanding your diagnosis and treatment
Managing a chronic condition through education and coaching
Finding new treatment options for your condition
Rare Disease
Cancer
Genetic Testing
Clinical Trial
Insurance/Billing
Other (please specify)
5.
What other help are you looking for? Select all that apply.
Medical records and/or medications review and organization
Someone to go to the doctor or hospital with me/them
Coaching to ask the right questions and get the most out of a doctor’s visit
Put together an action plan for a loved one’s treatment or care
Insurance and billing problems
Other (please specify)
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6.
What have you/they been diagnosed with? Please include the exact medical term for your condition/s, obtained from the physician.
(Required.)
Have you received a diagnosis? (Yes/No)
Primary
Second
Third
Fourth
I'm not comfortable answering at this time.
7.
When were you/they diagnosed with this condition?
Recently – less than 6 months ago
Diagnosed more than 6 months ago
Diagnosed before the age of 21
8.
Any other details you think I should know?
9.
How did you find Stepwise Patient Advocacy?
Web search (Google, etc.)
Patient Advocacy Website (APHA, NAHAC, GNA, etc.)
Family, friend, or acquaintance
Health Fair or Meeting
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Other (please specify)
