Template 患者資訊 Mpox 調查模板

Mpox 調查模板

Mpox 調查模板

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Mpox Survey Template

We value your input. Please take a few moments to complete this short survey about Mpox.
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1.
Age range
Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
2.
Gender identity
Male
Female
Non-binary
Prefer not to say
3.
Have you ever received a diagnosis of Mpox?
Yes
No
4.
If yes, when did the diagnosis occur?
5.
Which symptoms did you experience?
6.
Have you been vaccinated against Mpox?
Yes
No
7.
If yes, how many vaccine doses did you receive?
8.
Where did you learn about Mpox?[多選題]
Health professional
News articles
Social media
Friends/Family
Other
9.
Any other comments or concerns?
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Template instructions
猴痘調查模板旨在從公眾、患者和醫療保健提供者那裡收集有關猴痘(以前稱為猴痘)的信息。使用這個免費模板來衡量意識、症狀、疫苗接種覆蓋率、風險因素和獲得護理的機會。

該模板包括人口統計項目,例如年齡組和性別、有關診斷和疫苗接種的病史問題、症狀檢查表以及診斷日期和其他註釋的開放字段。問題簡潔,適合線上、診所或社區外展環境。它包括多項選擇和開放文本字段。

理想的用戶包括公共衛生機構、研究人員、醫院和進行監測、疫苗接種研究或社區宣傳活動的非政府組織。該表單支持隱私敏感數據收集,並且可以在 SurveyMars 中進行自定義以進行集成、電子簽名和報告。管理員可以匯出結果並產生摘要報告,以便快速做出決策。

按一下「使用此範本」以快速、安全地開啟、修改和部署 mpox 調查範本,並開始收集可操作的資料。

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