Literacy and Health Literacy Evaluation Form
Basic Information
Name
Age
Date
Literacy Evaluation
Highest Education Level
None
Primary School
Secondary School
High School
College/University
Other
Preferred Language
Can the person read instructions/materials?
Yes
No
Partially
Can the person write (e.g. fill out a form)?
Yes
No
Partially
Health Literacy Assessment
Understands health information provided?
Yes
No
Sometimes
Can follow medical instructions (e.g. taking medication)?
Yes
No
Sometimes
Can identify where to seek health information/resources?
Yes
No
Not Sure
Notes / Observations
Evaluator Name
Signature