Medication Effect Poll for Trial Participants
Please share your experience with the medication you received during the clinical trial. Your feedback is vital for evaluating the treatment's effectiveness and safety.
Participant Initials (for identification purposes only)
*
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Name of the medication you received
*
Date you took the medication
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How effective was the medication in treating your condition?
*
Not effective at all
1
2
3
4
Highly effective
5
1 is Not effective at all, 5 is Highly effective
Did you experience any side effects from the medication?
*
Yes
No
Please indicate the side effects you experienced (select all that apply)
Nausea
Headache
Dizziness
Fatigue
None of the above
Other
Please rate the severity of any side effects you experienced
Very mild
1
2
3
4
Very severe
5
1 is Very mild, 5 is Very severe
Please describe any other effects or comments about your experience
Overall, how satisfied are you with the medication?
*
1
2
3
4
5
Submit Feedback
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