Patient Evaluation and Survey Form
Compounding patient evaluation form
Did the compounding pharmacy personnel provide clear and concise counseling and instructions on drug therapy and delivery devices?
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5
Worst
Best
1 is Worst, 5 is Best
Were the compounding pharmacy personnel respectful, and did they offer immediate assistance?
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4
5
Worst
Best
1 is Worst, 5 is Best
Did all members of the compounding pharmacy team act in a professional manner at all times?
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5
Worst
Best
1 is Worst, 5 is Best
Did all members of the compounding pharmacy team appear to be well trained in their respective job duties?
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2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Was follow-up provided after the initial compounding consult or counseling session?
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4
5
Worst
Best
1 is Worst, 5 is Best
Additional comments on service provided:
Personnel review
Overall personnel rating
Pharmacist(s)
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3
4
5
Pharmacy technician(s)
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2
3
4
5
Delivery personnel(s)
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2
3
4
5
Other personnel(s)
1
2
3
4
5
Additional comments on pharmacy personnel:
Submit
Should be Empty: