Voluntary Survey:

You are invited to participate in a brief survey regarding medication safety.  This survey should take about 10 minutes to complete.  Participation is voluntary, and responses will be kept anonymous. 

You have the option to not respond to any questions that you choose.  Participation or nonparticipation will not impact your relationship with the drugstore where the survey is completed. Submission of the survey will be interpreted as your informed consent to participate and that you affirm that you are at least 18 years of age.

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1. Age

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2. Sex

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3. Home Zip Code

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4. Is it hard for you to talk to your pharmacist about your health care?

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5. Do you understand the instructions on the medicine bottle label?

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6. How many drugstores do you use?

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7. Do you prefer getting your medicine at the local drugstore or mailed to your home?

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8. Have you ever had any of these problems with your medicine? (Check all that apply)

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9. Who do you turn to if you do not understand how to take your medicine?  (Check all that apply)

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10. How many medicines do you take?

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11. Do you keep a medication list?

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12. If Question #11 is "Yes", How often is your medication list updated? (Check all that apply)

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13. If Question #11 is "Yes", Who has a copy of your medication list? (Check all that apply)

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