3-MONTH SURVEY - Template

Thank you for your participation in this program. In order to improve our program to help other patients, we’d like to ask you a few quick questions.

Name*

First Last

Are you a...*

What did you find most helpful about the program?*

(Please select all that apply)

Other: Please let us know what you found most helpful*

Did you click through to the web pages?*

Was the number of messages that you received…*

What would have made the program better?*

(Please select all that apply)

What other conditions would you have liked information on?*

Other: What would have made the program better?*

Overall, did you find this program helpful?*

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