Program Check-Ins | Patient Support Program

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Program Check-Ins

3-Month Check-In

This check-in helps us understand how you’re feeling after your first three months on the program. Please answer honestly so we can support you well.

Program Check-In

Please fill out all required information below.

First name*

Last name*

Email address*

Phone number

Have you been taking your medication as prescribed this week?*

Yes consistently

Most days

Sometimes

Not this week

Have you experienced any side effects?*

No

Mild

Moderate

Severe

How confident do you feel managing your medication and health this week?*

1 (not confident)

2

3

4

5 (very confident)

How have you been feeling overall this week?*

Did anything make it harder to stay on track this week?*

6-Month Check-In

We are halfway through your first year. This is a great time to reflect on your energy levels and your progress. Your feedback helps us refine our portal.

Program Check-In

Please fill out all required information below.

First name*

Last name*

Email address*

Phone number

Have you been taking your medication as prescribed this week?*

Yes consistently

Most days

Sometimes

Not this week

Have you experienced any side effects?*

No

Mild

Moderate

Severe

How confident do you feel managing your medication and health this week?*

1 (not confident)

2

3

4

5 (very confident)

How have you been feeling overall this week?*

Did anything make it harder to stay on track this week?*

12-Month Check-In

Your twelve-month milestone is a significant achievement in your health journey. This reflection helps us celebrate your progress and ensure you have the continued support needed for the year ahead.

Program Check-In

Please fill out all required information below.

First name*

Last name*

Email address*

Phone number

Have you been taking your medication as prescribed this week?*

Yes consistently

Most days

Sometimes

Not this week

Have you experienced any side effects?*

No

Mild

Moderate

Severe

How confident do you feel managing your medication and health this week?*

1 (not confident)

2

3

4

5 (very confident)

How have you been feeling overall this week?*

Did anything make it harder to stay on track this week?*

CONTACT US:

42 Arrow Rd,

Guelph, N1K 1S6, ON, CA

1325 6th Ave, 28th Floor

New York, 10019, NY, US

Tel: +1 - 877 -MEDUCOM

Fax: 519-767-2542
info@meducom.ca

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