Maintenance Therapy Treatment Assessment Form
Please complete this form to assess the effectiveness and experience of maintenance therapy treatment.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Maintenance Therapy
*
Please Select
Medication
Physical Therapy
Psychological Therapy
Lifestyle Modification
Other
Duration of Current Therapy (in months)
*
How effective do you feel the maintenance therapy has been?
*
Not effective
1
2
3
4
5
6
7
8
9
Highly effective
10
1 is Not effective, 10 is Highly effective
Please rate your adherence to the prescribed therapy plan.
*
1
2
3
4
5
Please indicate any side effects experienced during therapy.
*
No side effects
Mild fatigue
Nausea
Headache
Mood changes
Other
Please indicate the severity of any side effects you experienced.
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Nausea
5
6
7
8
Headache
9
10
11
12
Mood changes
13
14
15
16
Other
17
18
19
20
Has your overall quality of life improved since starting maintenance therapy?
*
Yes
No
Not sure
Additional comments or concerns (patient)
Clinician's assessment and recommendations
Submit Assessment
Should be Empty: