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

continue on the next page

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 _____________________

continue on the next page

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]