Autoimmune Patient Survey
1.
What is your age?
2.
What autoimmune condition do you have?
3.
Where do you currently receive your infusion/injection?
Hospital
Physician’s office
Ambulatory Infusion Center
Home
4.
Where else have you received it in the past?
5.
How would you rate your infusion experience 1-5? 1 being the worst and 5 being the best?
1
2
3
4
5
I do not receive infusions
6.
How did you find out about your infusion center, if you go to one?
Physician referral
Online search
Friend/family member
Insurance suggestion
Pharma patient support suggestion
Other
I do not go to an infusion center
7.
Did you get any education or support on your condition when you were diagnosed?
Yes
No
Some
8.
Have you done self-education or reached out to support groups for your condition?
Yes
No
9.
What services would you be interested in getting additional support?
Weight management programs
Nutrition and lifestyle coaching
Physical therapy
Behavioral/mental health
Access to other patients/patient community
Access to primary care
Cosmetic services while you receive your infusion
Medication management
Other
10.
Are you willing to pay out of pocket for the above services or only if covered by insurance?
Only if covered by insurance
Willing to pay out of pocket