Pritchett & Hull Patient Handout 2^nd  Month Follow- up Survey 

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Please complete and submit this form for each patient: (Questions 1-4 should be the same as initial form). 

1.      Medical Professional Name 

2.      City 

3.      Handout Evaluation                                                    

1.      Ease of use

a.       5 - excellent

b.      4    

c.       3 - average          

d.      2    

e.       1 - poor

2.      Ease of Understanding

a.       5 - excellent

b.      4    

c.       3 - average    

d.      2    

e.       1 - poor

 

3.      Pertinent to disease states

a.       5 - excellent

b.      4    

c.       3 - average         

d.      2    

e.       1 - poor

 

4.      Pertinent to your practice

a.       5 - excellent

b.      4    

c.       3 - average      

d.      2    

e.       1 - poor

 

5.      Information presented logical order.

a.       5 - excellent

b.      4    

c.       3 - average    

d.      2    

e.       1 - poor

4.  Value to your patients

 

1.      Help with understanding of disease state

a.       5 - excellent

b.      4    

c.       3 - average       

d.      2    

e.       1 - poor

 

2.      Help with reinforcement of your instructions

a.       5 - excellent

b.      4    

c.       3 - average    

d.      2    

e.       1 – poor 

 

5.  Did you find these handouts beneficial to your practice?

a.       5 - excellent

b.      4    

c.       3 - average     

d.      2    

e.       1 – poor

 

6.  Did you find these handouts beneficial to your patients?

a.       5 - excellent

b.      4    

c.       3 - average    

d.      2    

e.       1 – poor

 

7.  Do you feel these handouts increased patient compliance?

a.       5 - excellent

b.      4    

c.       3 - average    

d.      2    

e.       1 – poor

 

8.  Would you continue using handouts such as this?

a.       Definitely

b.      Highly Likely

c.       Possibly

d.      Not at all 

 

9.  Would you recommend this product to others?

e.       Definitely

f.        Highly Likely

g.       Possibly

h.       Not at all 

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