Pharmaceutical Patient Adherence Survey

Pharmaceutical Patient Adherence Survey — Form Fields

This surveys template includes 9 fields. Understand patient medication adherence behaviors and barriers to compliance. Free to customize and use on ZenBuild.

• How many prescription medications do you take? (dropdown selection, required) — options: 1, 2-3, 4-5, 6 or more
• Do you take your medication as prescribed? (multiple choice, required) — options: Always, Usually, Sometimes, Rarely
• What makes it difficult to take medication as prescribed? (checkboxes, optional) — options: Forgetting, Side Effects, Cost, Difficulty Swallowing, Complex Schedules, Feeling Better Without It
• How well does your medication manage your condition? (rating, required)
• Do you use a pill organizer or reminder app? (multiple choice, required) — options: Yes, No, Sometimes
• Comments about your medication experience (long text, optional)
• Satisfaction with Pharmacist Guidance (rating, required)
• Have you ever stopped taking medication without consulting your doctor? (multiple choice, required) — options: Yes, No
• Approximate age (number, optional)