Biologic Medication HCP Evaluation Form
Please complete this form to evaluate the healthcare professional’s use case and readiness related to biologic medication.
Evaluator Full Name
*
First Name
Last Name
Evaluator Email Address
*
example@example.com
Healthcare Professional’s Role
*
Please Select
Physician
Nurse Practitioner
Physician Assistant
Pharmacist
Other
Practice Setting
*
Please Select
Hospital
Clinic
Private Practice
Academic Institution
Other
Primary Diagnosis/Indication for Biologic Medication
*
Please Select
Rheumatoid Arthritis
Psoriasis
Inflammatory Bowel Disease (IBD)
Asthma
Other
Biologic Medication(s) Used
Adalimumab
Etanercept
Infliximab
Ustekinumab
Secukinumab
Other
Experience Level with Biologic Medications
*
Extensive (regularly prescribes/monitors)
Moderate (occasionally prescribes/monitors)
Limited (rarely prescribes/monitors)
No experience
Barriers or Challenges to Biologic Medication Use
Insurance/Cost Issues
Patient Adherence
Side Effects Concerns
Access to Medication
Lack of Experience/Training
Other
Readiness to Initiate or Manage Biologic Therapy
*
Fully ready and confident
Somewhat ready, needs further support
Not ready at this time
Additional Notes or Comments
Submit Evaluation
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