About this template
The Health Belief Model (HBM) Questionnaire is a vital tool for healthcare providers, health coaches, and researchers to understand a patient's psychological readiness to adopt healthy behaviors. By measuring key constructs such as perceived susceptibility, severity, benefits, and barriers, this form provides actionable insights into why a patient may or may not follow medical advice or lifestyle recommendations.
Using this Doc2Form template, you can quickly gather patient data to tailor your interventions. Whether you are working in a clinical setting or private practice, this structured approach helps you identify specific roadblocks to health compliance and build stronger, more effective patient-provider action plans.
Key features
- Assess all six core HBM constructs in one structured form.
- Mobile-responsive design for easy patient completion.
- Easily export responses to Sheets for trend analysis.
- Fully customizable to include specific health conditions.
- Streamline patient intake and health coaching workflows.
Use cases
- Pre-appointment patient health belief assessment.
- Health coaching progress tracking and goal setting.
- Academic research on health behavior change.
- Public health program evaluation and planning.
What this form collects
- Full Name (Short answer)Please enter your full legal name.
- Age (Short answer)Please enter your current age.
- Perceived Susceptibility (Linear scale)How likely do you feel you are to develop this health condition? (1 = Not at all likely, 5 = Extremely likely)
- Perceived Severity (Linear scale)How serious do you believe this health condition is? (1 = Not serious, 5 = Very serious)
- Perceived Benefits (Linear scale)How effective do you believe recommended actions are in reducing your health risk? (1 = Not effective, 5 = Very effective)
- Perceived Barriers (Paragraph)What obstacles prevent you from following health recommendations? Please describe.
- Perceived Self-Efficacy (Linear scale)How confident are you in your ability to take the recommended health actions? (1 = Not confident, 5 = Very confident)
- Cues to Action (Paragraph)What factors or events have prompted you to consider your health recently?
FAQ
What is the purpose of this HBM template?
It helps you identify a patient's perceptions regarding their health risks and the efficacy of potential interventions, allowing for more personalized care plans.
Can I customize the questions for a specific condition?
Yes, you can easily edit, add, or remove questions within the Google Form editor to better align with the specific health condition you are addressing.
How do I share this with my patients?
Once you have your form ready, you can share it via email, embed it on your secure patient portal, or provide a link during your consultation.
Is this form suitable for research purposes?
Yes, the structured nature of the Health Belief Model makes this template an excellent starting point for academic or clinical research projects.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.