Use our readymade template to create your FOSQ-10 screening tool for assessing the impact of sleep disorders on daily activities
Create your care assessments
- Prebuilt template with FOSQ-10 scoring to assess the impact of sleep disorders on daily activities
- 10-item questionnaire that scores each item from “1” (Yes, extreme) to “4” (No)
- Real-time calculation of FOSQ-10 Score based on the form responses
- Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
- Compare the scores from the initial screening with that of the followup to track the progression of sleep disorders
- Easily create responsive forms that allow patients to complete their assessments on any device at any time
Collect responses from your patients
| Patient ID | 1004 |
| Patient Name | John W |
| Patient Email | johnw@ymail.com |
| Patient Phone Number | 0987654321 |
| Doctor's Name | Dr. Smith |
| Location | New York |
| Select the appropriate answer for each statement | |
| Do you have difficulty concentrating on the things you do because you are sleepy or tired? | Yes, a little |
| Do you generally have difficulty remembering things, because you are sleepy or tired? | No |
| Do you have difficulty finishing a meal because you become sleepy or tired? | Yes, moderate |
| Do you have difficulty working on a hobby (for example, sewing, collecting, gardening) because you are sleepy or tired? | Yes, extreme |
| Do you have difficulty doing work around the house (for example, cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired? | Yes, a little |
| Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired? | No |
| Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired? | Yes, moderate |
| Do you have difficulty getting things done because you are too sleepy or tired to drive or take public transportation? | Yes, a little |
| Do you have difficulty taking care of financial affairs and doing paperwork (for example, writing checks, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired? | No |
| Do you have difficulty performing employed or volunteer work because you are sleepy or tired? | Yes, extreme |
| FOSQ-10 Score | 30 |
- Collect patient details such as patient id, name, email etc in the FOSQ-10 assessment form
- Send an email invitation with a secure link for patients to complete their FOSQ-10 assessment form prior to their visit
- Allow patients to save their progress and complete their FOSQ-10 assessment form at a later time without losing any responses
- Set up an email template for your FOSQ-10 assessment and automatically send invitation emails to multiple patients with ease
- Send a confirmation email to the patients with their FOSQ-10 score, diagnosis, next steps when they submit their FOSQ-10 assessment
Track patient responses in Google Sheets
| A | B | C | D | E | |
|---|---|---|---|---|---|
| 1 | Name | Question | Answer | Score | Total Score |
| 2 | John W | Do you have difficulty concentrating on the things you do because you are sleepy or tired? | Yes, a little | 3 | 30 |
| 3 | John W | Do you generally have difficulty remembering things, because you are sleepy or tired? | No | 4 | 30 |
| 4 | John W | Do you have difficulty finishing a meal because you become sleepy or tired? | Yes, moderate | 2 | 30 |
| 5 | John W | Do you have difficulty working on a hobby (for example, sewing, collecting, gardening) because you are sleepy or tired? | Yes, extreme | 1 | 30 |
| 6 | John W | Do you have difficulty doing work around the house (for example, cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired? | Yes, a little | 3 | 30 |
| 7 | John W | Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired? | No | 4 | 30 |
| 8 | John W | Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired? | Yes, moderate | 2 | 30 |
| 9 | John W | Do you have difficulty getting things done because you are too sleepy or tired to drive or take public transportation? | Yes, a little | 3 | 30 |
| 10 | John W | Do you have difficulty taking care of financial affairs and doing paperwork (for example, writing checks, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired? | No | 4 | 30 |
| 11 | John W | Do you have difficulty performing employed or volunteer work because you are sleepy or tired? | Yes, extreme | 1 | 30 |
- Export patient responses including the calculated FOSQ-10 score to Google Sheets for easy record-keeping
- Export individual points for 10 items to Google Sheets for data manipulation and analysis for comprehensive insights
- Use pre-built reports to easily keep track of patient progress over time and monitor changes in their sleep disorder symptoms
- Receive a copy of the response and the calculated FOSQ-10 score by email whenever a patient submits their FOSQ-10 assessment
- Use data in Google Sheets to integrate with external EHR systems for seamless data transfer
HIPAA compliance
| Patient ID: | 1004 |
| Patient Name: | ****** |
| Patient Email: | ****** |
| Patient Phone Number: | ****** |
| Doctor's Name: | Dr. Smith |
| Location: | New York |
| Select the appropriate answer for each statement | |
| Do you have difficulty concentrating on the things you do because you are sleepy or tired?: | Yes, a little |
| Do you generally have difficulty remembering things, because you are sleepy or tired?: | No |
| Do you have difficulty finishing a meal because you become sleepy or tired?: | Yes, moderate |
| Do you have difficulty working on a hobby (for example, sewing, collecting, gardening) because you are sleepy or tired?: | Yes, extreme |
| Do you have difficulty doing work around the house (for example, cleaning house, doing laundry, taking out the trash, repair work) because you are sleepy or tired?: | Yes, a little |
| Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?: | No |
| Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?: | Yes, moderate |
| Do you have difficulty getting things done because you are too sleepy or tired to drive or take public transportation?: | Yes, a little |
| Do you have difficulty taking care of financial affairs and doing paperwork (for example, writing checks, paying bills, keeping financial records, filling out tax forms, etc.) because you are sleepy or tired?: | No |
| Do you have difficulty performing employed or volunteer work because you are sleepy or tired?: | Yes, extreme |
| FOSQ-10 Score: | 30 |
| FOSQ-10 Score: | 30 |
- Create a HIPAA compliant FOSQ-10 assessment form to safely collect, store and access patient responses
- Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
- Automatically mask PHI fields when exporting FOSQ-10 form responses to Google Sheets and sending them on email
- Collect patient details in FOSQ-10 assessments by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize the risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
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