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Prescriber Feedback
Medication evaluation program feedback form
Clinic name
Clinic name
Medication
Medication
Number of patients prescribed
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
1
2
3
4
5
Q2. How do you rate the perceived quality of the medication
1
2
3
4
5
Q3. How do you rate your patient’s overall satisfaction with the medication
1
2
3
4
5
Q4. How likely are you to prescribe this medication, for an appropriate patient, in the future
1
2
3
4
5
If you were to prescribe the medication again, what would be the most likely symptom or condition?
If you were to prescribe the medication again, what would be the most likely symptom or condition?
Other comments
Other comments