Health Literacy Assessment Form

Health Literacy Assessment Form — Form Fields

This healthcare template includes 6 fields. Evaluates a patient's ability to understand and act on health information and instructions. Helps care teams tailor communication strategies and educational materials. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Highest level of education completed (dropdown selection, required) — options: Less than high school, High school diploma or GED, Some college, Associate's degree, Bachelor's degree or higher
• How confident are you filling out medical forms by yourself? (multiple choice, required) — options: Very confident, Somewhat confident, Not confident, I need help with forms
• Do you have any difficulty reading health-related materials? (multiple choice, required) — options: Never, Sometimes, Often, Always
• Preferred language for health information (dropdown selection, required) — options: English, Spanish, Mandarin, French, Other
• How do you prefer to receive health information? (checkboxes, optional) — options: Verbal explanation from provider, Written materials / pamphlets, Videos or visual aids, Patient portal / app, Family member present to help