Ask Ality Health Survey

1

What’s your name?* This field is required.

First Name

Last Name

2

What’s your email?* This field is required.

example@example.com

3

Are you currently diagnosed with a medical condition?* This field is required.Note: you must have a diagnosis to get a medication review

Yes

No, I don't have a diagnosis (I may or may not have symptoms)

My question for the specialist has nothing to do with a diagnosis

4

Do you want to talk to your specialist about your existing diagnosis?* This field is required.

Yes

No, I don't want to talk about/ask questions about my existing diagnosis

5

Regarding your diagnosis, which of the following statements best describes your situation?* This field is required.

I have doubts that my diagnosis is correct

I think my diagnosis is correct, but I want additional confirmation

I want a specialist with a different perspective/expertise to weigh in on the diagnosis

My diagnosis is correct. I just want to ask some questions about it

6

Are you receiving any treatment for your diagnosis?* This field is required.We're asking about doctor ordered treatments such as medications, surgeries, etc.

Yes

No

7

Do you have concerns/questions about your current treatment that you'd like to discuss with the specialist?* This field is required.If you want your medication reviewed, select yes here.

Yes

No, I don't want to discuss my treatments

8

Do you want to specifically talk about your medications with the specialist?* This field is required.

Yes

No, I want to talk about other treatments not including prescription medications

9

Regarding your treatment, which of the following statements best describes your situation?* This field is required.

I have doubts that my treatment is right for me

I think my treatment is right for me, but I want additional confirmation

I want a specialist with a different perspective/expertise to weigh in on my treatment

My treatment is right for me. I just want to ask some questions about it

10

Are you experiencing symptoms that you'd like to discuss with a specialist?* This field is required.

Yes

No, I want to talk about something else

11

Do you want to request a particular specialty to work with?* This field is required.

Yes, I know which type of doctor I want to help me

No, I'll let your clinical team determine the most appropriate specialty for me

12

Please select the specialty you'd like to request.* This field is required.

13

Recommended Service

14

specialty

15

Recommended service based on your survey results: {recommendedService}

from the specialty: {recommendationBased61}

The next screen will take you to checkout. After, we'll ask you for some additional details about your health to provide to your specialist. You'll be able to include any information you think is important for your specialist to consider.

16

Bat Size Recommendations

17

Checkout* This field is required.

My Bag

1

Specialist Q&A/Second OpinionYour specialist will provide personalized answers for your unique situation and goals. Satisfaction guaranteed.
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First Name

Last Name

18

Unique ID