Hospital Questionnaire

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STROKE PATIENT BEHAVIOR QUESTIONNAIRE

By helping us better understand what happened and how you or your loved ones responded to their stroke.

You can help us save countless lives.

Let's go.

Let‘s Go!

Before we get started.

Please Fill In Your Details

Please select the hospital you were admitted to from the list below.

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Terms & Conditions.

Details

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Patient’s Age

Please fill in your age in years.

Enter Age

70

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Which of the following items described the symptoms the patient experienced?

Select Multiple

They suddenly had problems with their balance making them feel unsteady, for example when standing or walking.

Sudden confusion, they did not know where they were or did not recognise people around them.

The patient found it difficult to form and pronounce words.

The patient had trouble finding the correct words, had long pauses between words or was speaking one syllable at a time.

The patient kept colliding with objects or structures such as door frames on one side of their body. It was as if they did not see it.

Sudden weakness of the face, causing it to droop down on one side.

The patient was gazing into one direction, it was as if they were unable to move their eyes.

Sudden loss of coordination. Such as irregular, uncoordinated movement, instability of gait or difficulty with using their hands to grasp objects.

The patient suddenly lost consciousness and did not respond when attempting to wake them up.

They kept covering and uncovering their eyes. Then blinking as they had trouble seeing.

Sudden weakness of the arm, especially on one side.

Sudden weakness of the leg, especially on one side.

The patient could not understand what others was saying. It was as if people were speaking a foreign language all of a sudden.

They had a sudden altered or complete loss of sensation on their arm or leg on one side of the body compared to the other.

Sudden severe "Thunderclap" headache like never experienced before. It almost felt like someone hit them over the head with something.

The patient suddenly felt very dizzy or drunk. It was like the world was spinning around them. They had to hold on to something in order not to fall.

The patient suddenly started vomiting.

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When the patient developed the symptoms that brought them to the hospital, what did they FIRST think was wrong?

Choose One

Stroke

Other

Not sure

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Whom did the patient first call or speak with after their symptoms started?

Select One

Ambulance

GP

Pharmacists

Family member

e.g., spouse, children, siblings.

Friend

Other

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If they called the ambulance, what number did they use?

Which phone number should you use to call an ambulance?

Emergency number

*If you are not sure you can skip this question

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What were the main reasons the patient did not immediately call an ambulance?

Select Multiple

They thought/hoped the symptoms will disappear in a while.

They did not think the symptoms were serious.

They wanted to call the family doctor to ask for their opinion first.

They called a relative or friend to ask advice first

They were reluctant to go to hospital for fear of the hospital/doctors/tests.

They were concerned about what everything would cost.

They did not think there is anything that doctors could do.

They did not call an ambulance as someone (family members/friends) drove them to the hospital.

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What was the reaction of the person you first called or spoke with after your symptoms started?

Select one

Encouraged me to call or helped me to call an ambulance.

Encouraged me to call or took me to my General practitioner.

Encouraged me to go to the hospital

Drove me to the hospital

Other

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How did the patient arrive at the hospital?

Select One

By ambulance

Drove themselves to hospital

Was driven to hospital by a friend/relative

Taxi

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How did the patient decide to come to this particular hospital?

Select one

It was the closest hospital to their home.

They knew this hospital specialised in stroke treatment.

They knew the hospital had an emergency department.

They knew this hospital has good facilities.

They were referred by their GP.

They were referred by or transferred from another hospital to this one.

Other

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At what time was the last time you saw the patient normal?

Wednesday

Time

12

:

00

I’m not sure

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What time did the patient arrive at this hospital?

Wednesday

Time

12

:

00

Please check your dates. The last time you saw the patient normal is set on the previous page as being after they arrived at hospital.

I’m not sure

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How long do you estimate it was between the onset of symptoms and arriving at this hospital?

Select one

2 hours and 4 minutes

Less than two hours.

Less than four hours.

More than four hours.

Continue

DONE!

Thank you so much for taking this time to help others who may suffer stroke in the future.

As a token of our appreciation we have a free Stroke Home Care Manual for you. This may help you deal with the new reality of living with stroke at home.

Download Stroke Care

Stroke affects people in different ways, but there is life after stroke! It really does help to get in touch with someone who has been through what you are going through. For a list of local Stroke Patient Support organizations click here.

Local Patient Support Organizations

Sometimes some good can come from a bad experience. If you want to use your experience to make a difference in the world and help us teach others about the signs and symptoms of stroke, or even if you just want to help your own family better understand what stroke is, please have a look at the FAST Heroes website.

Together we can save the world - One Grandparent at a time.

FAST Heroes Website

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