Medication evaluation program feedback form

Clinic name
Number of patients prescribed

Based on the feedback you received, please rate this medication on a scale of 1 to 5, where 1 is low and 5 is high:
Q1. How do you rate the perceived efficacy of the medication
Q2. How do you rate the perceived quality of the medication
Q3. How do you rate your patient’s overall satisfaction with the medication
Q4. How likely are you to prescribe this medication, for an appropriate patient, in the future
If you were to prescribe the medication again, what would be the most likely symptom or condition?
Other comments