SurveyMonkey Powered Online Survey

Medication Adherence

The following survey was developed by the Clinical and Patient Educators Association (CPEA) to assess your use of prescription medications for ongoing medical conditions. All answers will remain completely anonymous.

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* 1. Please specify on whose behalf you are completing this survey (or please specify who is completing this survey):

On my own behalf, I am the patient

On behalf of a patient in my family

Oh behalf of a patient whom I am the primary caregiver

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* 2. Please provide the age range of the patient:

21 and Under

22 to 34

35 to 44

45 to 54

55 to 64

65 and Over

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* 3. Patient is:

Male

Female

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* 4. Please select the therapeutic areas in which the patient has/had a healthcare condition during the past year:

Cancer (Breast, Colon, Leukemia, etc.)

Pain (Chronic pain, Fibromyalgia, Gout, etc.)

Diabetes (Type I, Type II)

Infectious disease (HIV, Hepatitis B/C, MRSA, etc.)

Cardiovascular (High blood pressure, High cholesterol, Stroke, etc.)

Neurology (MS, Parkinson's, Alzheimer's etc.)

Other (please specify)