Healthcare Treatment Plan Effectiveness Assessment
Please complete this form to help us evaluate the effectiveness of your current healthcare treatment plan.
Patient Full Name
*
First Name
Last Name
Patient Email Address
*
example@example.com
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Plan Name or Description
*
Duration on Current Treatment Plan (in weeks)
*
Primary Health Condition Being Treated
*
Please Select
Diabetes
Hypertension
Chronic Pain
Depression/Anxiety
Other
Please rate the following aspects of your treatment plan:
*
Rows
Not at all effective
Slightly effective
Moderately effective
Very effective
Extremely effective
Symptom improvement
1
2
3
4
5
Side effect management
6
7
8
9
10
Ease of following plan
11
12
13
14
15
Communication with provider
16
17
18
19
20
Overall satisfaction with your treatment plan
*
1
2
3
4
5
Have you experienced any side effects from your treatment plan?
*
No
Yes, mild
Yes, moderate
Yes, severe
How likely are you to recommend this treatment plan to others with a similar condition?
*
Not likely
1
2
3
4
5
6
7
8
9
Extremely likely
10
1 is Not likely, 10 is Extremely likely
Additional comments or suggestions regarding your treatment plan
Submit Assessment
Should be Empty: