Treatment Response Survey

Treatment Response Survey
We hope to gather better statistics about how patients have responded to maraviroc and/or anti-coagulation treatment and to be able to better predict who is likely to benefit.

The questionnaire should take only about 2 minutes. It is HIPAA compliant.
Name

First NameLast Name
Email
example@example.com
Which treatments have you tried?*

MaravirocAnti-coagulation
Maraviroc
Did you take a statin with maraviroc?*

Atorvastatin (Lipitor)Rosuvastatin (Crestor)Simvastatin (Zocor)Pravastatin (Pravachol)NoneOther
Did you take an anti-platelet medication with maraviroc?*

AspirinClopidogrel (Plavix)NoneOther
Did you receive this treatment from a RTHM clinician?

YesNo
Overall, to what extent have you benefited from maraviroc (and statin/anti-platelet)?*

1

2

3

4

5

1 is Little or none, 5 is Very significant
Overall, to what extent have you experienced side effects from maraviroc (and statin/anti-platelet)?*

1

2

3

4

5

1 is Little or none, 5 is Very significant
Please let us know any additional comments about how maraviroc (and statin/anti-platelet) treatment has impacted you.
Anti-coagulation
Which anti-coagulation medications did you take or are taking?*

Clopidogrel (Plavix)Apixaban (Eliquis)AspirinHeparinDabigatran (Pradaxa)Ticagrelor (Brillinta)NattokinaseSerrapeptaseLumbrokinaseOther
Did you receive this treatment from a RTHM clinician?

YesNo
Overall, to what extent have you benefited from anti-coagulation treatment?*

1

2

3

4

5

1 is Little or none, 5 is Very significant
Overall, to what extent have you experienced side effects from anti-coagulation treatment?*

1

2

3

4

5

1 is Little or none, 5 is Very significant
Please let us know any additional comments about how anti-coagulation treatment has impacted you.
Should be Empty:

Treatment Response Survey

Maraviroc

Anti-coagulation