Personalized Medicine Treatment Selection Form
Please complete this survey to help your clinician understand your health condition, treatment goals, preferences, and any prior experiences. This information will support a personalized discussion of treatment options.
What is your primary health condition or diagnosis?
*
Which of the following best describes your main treatment goal?
*
Reduce symptoms
Improve quality of life
Prevent disease progression
Minimize side effects
Other
Which treatment methods are you open to considering?
*
Oral medication
Injectable medication
Physical therapy
Lifestyle changes
Other
Have you tried any treatments for this condition before?
*
Yes
No
Please rate your experience with previous treatments.
Rows
Effectiveness
Side effects
Very poor
1
2
Poor
3
4
Average
5
6
Good
7
8
Excellent
9
10
How important are the following factors in your treatment selection?
*
Rows
Not important
Somewhat important
Very important
Convenience (ease of use)
11
12
13
Cost/insurance coverage
14
15
16
Minimizing side effects
17
18
19
Speed of results
20
21
22
Clinician recommendation
23
24
25
How would you rate your tolerance for potential side effects?
*
1
2
3
4
5
Are there any constraints or barriers to treatment you would like to share?
Cost/insurance limitations
Transportation/access issues
Work or family commitments
Other health conditions
Other
How involved do you wish to be in making treatment decisions?
*
I prefer my clinician to decide
I prefer to decide together with my clinician
I prefer to make the final decision myself
Is there anything else you would like your clinician to know regarding your treatment preferences?
Submit
Should be Empty: