Whiplash Disability Questionnaire
21 reviews
21K+
Installs

Use our readymade template to create your Whiplash Disability Questionnaire (WDQ) for assessing the impact of whiplash injury on a patient's lifestyle

Create your care assessments

WDQ score Proposed treatment
0-30 Mild impact, may not need treatment
31-70 Moderate impact, consider therapy
71-100 Severe impact, immediate treatment
  • navigate_next Prebuilt template with WDQ scoring to assess the presence of whiplash injury and measure its impact
  • navigate_next 13-item questionnaire that scores each item on a scale of 0 to 10
  • navigate_next Real-time calculation of WDQ Score based on the form responses
  • navigate_next Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
  • navigate_next 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
1. How much pain do you have today? 5
2. Do your whiplash symptoms interfere with your personal care (washing, dressing etc)? 3
3. Do your whiplash symptoms interfere with your work/home/study duties? 4
4. Do your whiplash symptoms interfere with driving or using public transport? 2
5. Do your whiplash symptoms interfere with sleep? 6
6. Do you feel more tired/fatigued than usual since your injury? 5
7. Do your whiplash symptoms interfere with social activity? 4
8. Do your whiplash symptoms interfere with sporting activity? 3
9. Do your whiplash symptoms interfere with non-sporting leisure activity? 2
10. Do you experience sadness/depression as a result of your whiplash injury/symptoms? 1
11. Do you experience anger as a result of your whiplash injury/symptoms? 2
12. Do you experience anxiety as a result of your whiplash injury/symptoms? 3
13. Do you have difficulty concentrating as a result of your whiplash injury/symptoms? 4
WDQ Score 44
  • navigate_next Pre-populate patient details such as patient id, name, email etc in the WDQ assessment form before sharing it with the patients
  • navigate_next Send an email invitation with a secure link for patients to complete their WDQ assessment form prior to their visit
  • navigate_next Allow patients to save their progress and complete their WDQ assessment form at a later time without losing any responses
  • navigate_next Set up an email template for your WDQ assessment and automatically send invitation emails to multiple patients with ease
  • navigate_next Send a confirmation email to the patients with their WDQ score, diagnosis, next steps when they submit their WDQ assessment

Track patient responses in Google Sheets

A B C D E
1 Name Question Answer Score Total Score
2 John W 1. How much pain do you have today? 5 5 44
3 John W 2. Do your whiplash symptoms interfere with your personal care (washing, dressing etc)? 3 3 44
4 John W 3. Do your whiplash symptoms interfere with your work/home/study duties? 4 4 44
5 John W 4. Do your whiplash symptoms interfere with driving or using public transport? 2 2 44
6 John W 5. Do your whiplash symptoms interfere with sleep? 6 6 44
7 John W 6. Do you feel more tired/fatigued than usual since your injury? 5 5 44
8 John W 7. Do your whiplash symptoms interfere with social activity? 4 4 44
9 John W 8. Do your whiplash symptoms interfere with sporting activity? 3 3 44
10 John W 9. Do your whiplash symptoms interfere with non-sporting leisure activity? 2 2 44
11 John W 10. Do you experience sadness/depression as a result of your whiplash injury/symptoms? 1 1 44
12 John W 11. Do you experience anger as a result of your whiplash injury/symptoms? 2 2 44
13 John W 12. Do you experience anxiety as a result of your whiplash injury/symptoms? 3 3 44
14 John W 13. Do you have difficulty concentrating as a result of your whiplash injury/symptoms? 4 4 44
  • navigate_next Export patient responses including the calculated WDQ score to Google Sheets for easy record-keeping
  • navigate_next Export individual points for 13 items to Google Sheets for data manipulation and analysis for comprehensive insights
  • navigate_next Use pre-built reports to easily keep track of patient progress over time and monitor changes in their whiplash symptoms
  • navigate_next Receive a copy of the response and the calculated WDQ score by email whenever a patient submits their WDQ assessment
  • navigate_next 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
1. How much pain do you have today?: 5
2. Do your whiplash symptoms interfere with your personal care (washing, dressing etc)?: 3
3. Do your whiplash symptoms interfere with your work/home/study duties? : 4
4. Do your whiplash symptoms interfere with driving or using public transport?: 2
5. Do your whiplash symptoms interfere with sleep?: 6
6. Do you feel more tired/fatigued than usual since your injury?: 5
7. Do your whiplash symptoms interfere with social activity? : 4
8. Do your whiplash symptoms interfere with sporting activity? : 3
9. Do your whiplash symptoms interfere with non-sporting leisure activity?: 2
10. Do you experience sadness/depression as a result of your whiplash injury/symptoms? : 1
11. Do you experience anger as a result of your whiplash injury/symptoms? : 2
12. Do you experience anxiety as a result of your whiplash injury/symptoms?: 3
13. Do you have difficulty concentrating as a result of your whiplash injury/symptoms?: 4
WDQ Score: 44
WDQ Score: 44
  • navigate_next Create a HIPAA compliant WDQ assessment form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
  • navigate_next Automatically mask PHI fields when exporting WDQ form responses to Google Sheets and sending them on email
  • navigate_next Prepopulate patient details in WDQ assessments by creating secure prefill links without exposing PHI
  • navigate_next 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.

July 27, 2023

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

February 16, 2024

1 stars

Does not work

— Myles Sicuro

October 30, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S

More...
close