Hayden's Pharmacy

Family Owned and Serving the Youngwood and Surrounding Areas Since 1992

PATIENT HEALTH SURVEY FOR CLINICAL SERVICES

At Hayden’s Pharmacy, we CARE about our patients!  We ask that you help us help you by completing this survey.

There are no right or wrong answers – we just want to know what is true for you.

Please answer the following questions and submit the survey back to our team.

Thank you !

HEALTH RISK ASSESSMENT PA PHARMACY CARE NETWORK
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By selecting "I agree" below, you are agreeing with the information supplied for the Hayden's Pharmacy Clinical Survey.

Taking part of this survey is voluntary. The health information that is received will allow our team to improve your wellbeing and encourage healthy habits. The information does not diagnosis illnesses or health problems. It does not replace any medical or treatment advice from the patient's healthcare provider.

All answers are private and kept confidential. This information may be shared with healthcare team members to help improve the patients health. The healthcare plan created and summary reports maybe shared with hospitals, healthcare providers, and pharmacists. These reports will not include your personal information only your medical information submitted. *

PLEASE ANSWER AND COMPLETE THE FOLLOWING HEALTH SURVEY QUESTIONS:

Who is completing this form? *
What is your / the patient gender ? *
What is your / the patient's ethnicity? *
Who is completing this form? *

Hayden's Pharmacy