article critique project
How Well Do you Know your Prescription Medications
answer each of the following questions carefully . You do not have to put your name on this sheet in to protect your privacy This survey is used for educational purposes only
1 . What is your gender ( circle one ) M F
2 . What is your age range ( circle one
18-24
25-32
33-40
41-55
55-70
70
3 . What is your race ( circle one
White
Hispanic
African-American
Native American
Asian /Pacific Islander
Other
4 . What is [banner_entry_middle]
your approximate family yearly income ( circle one
under 20 ,000 21 ,000 – 40 ,000 41 ,000 – 60 ,000 61 ,000 – 80 ,000 80 ,000 – 100 ,000 101 , 000 and up
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5 . What is the highest level of education you have received circle one less than high school
some high school
high school graduate
some college
2-year college degree
4-year college degree
graduate school degree
doctoral degree
6 . Which location best describes your place of residence circle one Northeastern US
Southeastern US
Great Lakes region
Midwestern US
Pacific Northwest
West Coast
Alaska
Hawaii 7 . How many prescription medications do you take on a daily basis ( circle one 1-2
3-5
5-8
9
8 . If you know them , write the names of the medications you take on the following lines . If you do not know all the names , write as many as you can think of
Prescription 1 _____________________ Prescription 6 _____________________
Prescription 2 _____________________ Prescription 7 _____________________
Prescription 3 _____________________ Prescription 8 _____________________
Prescription 4 _____________________ Prescription 9 _____________________
Prescription 5 _____________________
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9 . What do you take each of your prescription medications for ? In other words , what are the purposes of your prescription medication answer on the lines below
Prescription 1 _____________________ Prescription 6 _____________________
Prescription 2 _____________________ Prescription 7 _____________________
Prescription 3 _____________________ Prescription 8 _____________________
Prescription 4 _____________________ Prescription 9 _____________________
Prescription 5 _____________________
10 . How many times a day do you take each prescription medication ( circle
Prescription 1 one time two times three times more than three times
Prescription 2 one time two times three times more than three times
Prescription 3 one time two times three times more than three times
Prescription 4 one time two times three times more than three times
Prescription 5 one time two times three times more than three times
Prescription 6 one time two times three times more than three times
Prescription 7 one time two times three times more than three times
Prescription 8 one time two times three times more than three times
Prescription 9 one time two times three times more than three times
11 . How often do you forget to take your prescription medication in a month ‘s time ( circle
Prescription 1 never 1-2 times 3-5 times more than 5 times
Prescription 2 never 1-2 times 3-5 times more than 5 times
Prescription 3 never 1-2 times 3-5 times more than 5… [banner_entry_footer]
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