Data Dictionary Demo - Stroke - Patient Reported (TypeForm Style)

Welcome to the Patient-Reported Form

This interactive form collects information about your health and living situation following a stroke.

You can navigate through the questions using the buttons below or your keyboard (arrow keys).

Question 1 of 10

What is your ethnicity?

Varies by country and should be determined by country (not for cross country comparison)

Question 2 of 10

Where were you living prior to your stroke?

Most recent place of residence before your stroke or transient ischaemic attack (TIA)

Question 3 of 10

Where are you living now?

Your current living situation after your stroke or TIA

Question 4 of 10

Did you live alone prior to your stroke?

Your living arrangement before your stroke or TIA

Yes, I lived alone No, I shared my household with spouse/partner or other person (e.g. sibling, children, parents) Unknown

Question 5 of 10

Do you live alone now?

Your current living arrangement after your stroke or TIA

Yes, I live alone No, I share my household with spouse/partner or other person (e.g. sibling, children, parents) Unknown

Question 6 of 10

How would you describe your ability to walk before your stroke?

Your mobility status prior to your stroke or TIA

I could walk without help from another person, with or without a device I needed help from another person to walk I could not walk Unknown

Question 7 of 10

How would you describe your ability to use the toilet before your stroke?

Your toileting abilities prior to your stroke or TIA

I could use the toilet without help from another person I needed help from another person to use the toilet I could not use the toilet (e.g., used bedpan, had indwelling catheter) Unknown

Question 8 of 10

How would you describe your ability to dress yourself before your stroke?

Your dressing abilities prior to your stroke or TIA

I could dress myself without help from another person I needed help from another person to dress myself I could not dress myself Unknown

Question 9 of 10

How would you rate your quality of life today?

On a scale from 0 to 100, where 0 is the worst quality of life you can imagine and 100 is the best

50

0 - Worst 100 - Best

Question 10 of 10

Is there anything else you would like to share about your health or recovery?

Optional: Any additional information you think might be helpful

Thank You!

Your responses have been recorded.

This information will help us better understand stroke outcomes and improve care.

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