Oxytocin Treatment Feedback Form
Please provide feedback about your experience with oxytocin treatment to help us improve patient care.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is the primary reason you were prescribed oxytocin?
*
When did you start your oxytocin treatment?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is/was your prescribed dosage and frequency? (e.g., 10 IU daily)
*
How long have you been on oxytocin treatment?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Please rate the effectiveness of oxytocin treatment for your condition.
*
1
2
3
4
5
Which symptoms have improved since starting oxytocin treatment? (Select all that apply)
Mood
Energy levels
Social interaction
Anxiety reduction
Sleep quality
Other
Have you experienced any side effects? (Select all that apply)
Headache
Nausea
Drowsiness
Irritability
None
Other
How would you rate your overall satisfaction with oxytocin treatment?
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
Please share any additional comments, suggestions, or concerns regarding your oxytocin treatment.
Submit Feedback
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