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Patient Feedback
Patient First Program Evaluation Form
Clinic name
Clinic name
Medication
Medication
Number of units prescribed
Number of units prescribed
Please rate this medication on a scale of 1 to 5, where 1 is low and 5 is high:
Q1: How satisfied are you with this medication in addressing your medical needs?
1
2
3
4
5
Q2: How would you rate your overall experience while taking this medicine?
1
2
3
4
5
Q3: How likely are you to continue treatment with the medication in the future?
1
2
3
4
5
Are there any challenges you encountered using this medication?
Are there any challenges you encountered using this medication?
What symptom or condition are you seeking treating with this medication?
What symptom or condition are you seeking treating with this medication?
Other comments
Other comments