EXIT Community Survey Older Adults This anonymous survey will help community partners understand prescription use in older adults and help us in planning for community initiatives. Next Question Question Title * 1. Are you over the age of 60 years? Yes No Other (please specify) Next Question Question Title * 2. What is your gender? Male Female Other (please specify) Next Question Question Title * 3. What is your zip code? Next Question Question Title * 4. What is your race/enthnicity? White Black Hispanic American Indian/Alaskan Native Other Pacific Islander Asian/Native Hawaiian Other Unknown Next Question Question Title * 5. Do you take prescription medication? Yes No Other (please specify) Next Question Question Title * 6. Are you able to afford your medication? Yes No Other (please specify) Next Question Question Title * 7. Are all of your doctors aware of the various medications that you take? Yes No Other (please specify) Next Question Question Title * 8. In the past year have you tried to cut down on the drugs or medications you are taking? Yes No Other (please specify) Next Question Question Title * 9. In the past year have you used prescription or other drugs more than you meant to? Yes No Other (please specify) Next Question Question Title * 10. Do you find it difficult or confusing to read your prescription labels (bottle, box, etc)? Yes No Other (please specify) Next Question Question Title * 11. Do you have concerns about taking the wrong medication? Yes No Next Question Question Title * 12. How often do you forgot if you took your medication(s)? Often Sometimes Never Other (please specify) Next Question Question Title * 13. What reminders work well for you (indicate all that apply) Pillbox Alarm Blister pack Automated medication machine Other (please specify) Next Question Question Title * 14. In the past year have you been prescribed pain killers such as Vicodin, Oxycodone, Tramadol or other related opiate medications? Yes No Other (please specify) Next Question Question Title * 15. Where did you obtain your pain killer medications? (Indicate all that apply) Prescribed, filled at pharmacy Shared with friend or relative Other (please specify) Next Question Question Title * 16. Have alternatives been given to you for pain relief? Yes No Other (please specify) Next Question Question Title * 17. Have you been told by a doctor that you may have an addiction problem? Yes No Other (please specify) Next Question Question Title * 18. Have you adjusted the amount of cocktails (including wine and/or beer) due to the medications you are taking? Yes, I have decreased the amount of alcohol I consume Yes, I have increased the amount of alcohol I consume No, my drinking habits are about the same I do not drink alcohol Next Question Question Title * 19. Enter your name and address if you would like to be entered in a random drawing for a gift card. If you would like to remain anonymous, please skip this field. Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Next Question THANK YOU!