This anonymous survey will help community partners understand prescription use in older adults and help us in planning for community initiatives.

Are you over the age of 60 years?

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* 1. Are you over the age of 60 years?

What is your gender?

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* 2. What is your gender?

What is your zip code?

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* 3. What is your zip code?

What is your race/enthnicity?

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* 4. What is your race/enthnicity?

Do you take prescription medication?

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* 5. Do you take prescription medication?

Are you able to afford your medication?

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* 6. Are you able to afford your medication?

Are all of your doctors aware of the various medications that you take?

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* 7. Are all of your doctors aware of the various medications that you take?

In the past year have you tried to cut down on the drugs or medications you are taking?

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* 8. In the past year have you tried to cut down on the drugs or medications you are taking?

In the past year have you used prescription or other drugs more than you meant to?

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* 9. In the past year have you used prescription or other drugs more than you meant to?

Do you find it difficult or confusing to read your prescription labels (bottle, box, etc)?

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* 10. Do you find it difficult or confusing to read your prescription labels (bottle, box, etc)?

Do you have concerns about taking the wrong medication?

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* 11. Do you have concerns about taking the wrong medication?

How often do you forgot if you took your medication(s)?

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* 12. How often do you forgot if you took your medication(s)?

What reminders work well for you (indicate all that apply)

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* 13. What reminders work well for you (indicate all that apply)

In the past year have you been prescribed pain killers such as Vicodin, Oxycodone, Tramadol or other related opiate medications?

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* 14. In the past year have you been prescribed pain killers such as Vicodin, Oxycodone, Tramadol or other related opiate medications?

Where did you obtain your pain killer medications?  (Indicate all that apply)

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* 15. Where did you obtain your pain killer medications?  (Indicate all that apply)

Have alternatives been given to you for pain relief?

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* 16. Have alternatives been given to you for pain relief?

Have you been told by a doctor that you may have an addiction problem?

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* 17. Have you been told by a doctor that you may have an addiction problem?

Have you adjusted the amount of cocktails (including wine and/or beer) due to the medications you are taking?

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* 18. Have you adjusted the amount of cocktails (including wine and/or beer) due to the medications you are taking?

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.

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* 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.

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