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STROKE PATIENT BEHAVIOR QUESTIONNAIRE
By helping us better understand what happened and how you or your loved one responded to their stroke, you can help us save countless lives.
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
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 / numbness of the arm, especially on one side.
Sudden weakness / numbness 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 loss of sensation on their arm or leg on one side of the body compared to the other.
Sudden severe headache with no known cause.
The patient sudden felt very dizzy / drunk. It was like the world was spinning around them. They had to hold on to something in order not to fall over.
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
Relative
Friend
Other
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If they called the ambulance, what number did they use?
Enter 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 seek emergency care by calling 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.
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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 an ambulance.
Encouraged me to call my General practitioner.
Encouraged me to go to the hospital
Drove me to the hospital
Recommended that I wait to see if my symptoms improved.
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
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 the 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 the hospital?
Select One
2 hours and 4 minutes
Less than two hours
less than 4 hours
More than 4 hours
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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.
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.
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.
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