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  2. 2013
  3. March
  4. M
  5. Medication Instruction Survey
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Exit Survey
 
 
What is your age?
 
18 to 24
 
25 to 34
 
35 to 44
 
45 to 54
 
55 to 64
 
65 to 74
 
75 or older
 
 
 
What is the highest level of education you have completed?
 
8th grade or less
 
9th grade
 
10th grade
 
11th grade
 
Graduated from high school
 
1 year of college
 
2 years of college
 
3 years of college
 
Graduated from college
 
Some graduate school
 
Completed graduate school
 
 
 
Do you have insurance that covers medications?
 
Yes
 
No
 
Don't know
 
 
 
Do you have any chronic medical conditions?
 
Yes
 
No
 
 
 
Do you have any of the following? (Check all that apply)
 
wear glasses
 
legally blind
 
wear hearing aids
 
arthritis in your hands or difficulty open things with your hands
 
have problems understanding or remembering information
 
any mental or central nervous system problems or diagnosis (this includes strokes, depression, etc.)

 
 
 
Do you have a regular doctor or nurse practioner that you see on a regular basis and/or when you are sick?
 
Yes
 
No
 
 
 
Have you ever not taken a medication or completed a medication that your doctor or nurse practitioner had prescribed?
 
Yes
 
No (Please skip the next question)
 
 
 
Why did you not take or stop the medication that was prescribed to you? (Mark all that apply)
 
The cost of the medication was too high
 
The side effects were unbearable
 
I don't think the medication was helping me
 
I felt better after awhile and decided to stop taking it
 
It was too hard to keep taking the medication
 
The medication required me to take too many doses each day
 
I am not sure why I was taking the medication
 
I was switched to another medication after speaking with my doctor/nurse practitioner
 
I switched to an over the counter medication that was recommended to me by a healthcare professional
 
I switched to an over the counter medication that was recommended to me by a friend or relative
 
I switched to a herbal remedy
 
I just did not want to take or continue to take the medication
 
I did not trust my doctor/nurse practitioner
 
I do not trust the medication developers and/or medication companies
 
I found out something about the medication on the TV, in the newspaper or from a person that the medication was involved in lawsuits

 
 
 
What do you think picture #1 is telling you about taking a medication (there are no wrong or right answers)?
   
 
 
 
What do you think picture #2 is telling you about taking a medication (there are no wrong or right answers)?
   
 
Thank you for participating!