Pharmacy Clinical Services – Participant Survey Pharmacy Clinical Services - Participant Survey Please take a moment to complete this Feedback Form following your Pharmacist Clinical Service. Your opinion is important to us. We use this information to improve upon our current programs and develop services to best meet your health care needs. The information you provide is kept in a confidential and secure manner at MHCSI. If you are human, leave this field blank. Pharmacist Clinical Service Received * Basic Medication Review Advanced Medication Review Disease State Management Service Date * Pharmacy Providing the Service Do you feel you have a better understanding of the medications you are currently taking? * Yes No Please explain why or why not. * Have you made any changes to your medication use/management? (E.g. miss fewer doses, taking at proper time, taking different medication, etc.) * Yes No Please explain why or why not. * Have you made any changes in any other health related-behaviors? (E.g. diet, exercise, smoking cessation, etc.) * Yes No Please explain why or why not. * Have you made any productivity gains? * Missed less work/school Better performance at work/school Better “Quality of Life” (e.g. feel better, more energy, etc.) OtherOther Please rate the information provided by your pharmacist during this service * Not at all Satisfied Somewhat Satisfied Satisfied Very Satisfied Extremely Satisfied Please rate the value of this pharmacy clinical service * Not at all Valuable Somewhat Valuable Valuable Very Valuable Extremely Valuable Would you recommend this service to others? * Yes No Please explain why or why not. * Please add any additional comments or suggestions you may have.
