Factors Influencing Patient Adherence Survey

1. How old are you?

Under 18 18-24 25-34 35-44 45-54 55-64 65+

2. What factors may influence your medication adherence? (Select all that apply)

Lack of understanding about the medication Forgetting to take medications Side effects of medications Difficulty following the treatment plan Financial constraints Fear or concerns about efficacy/safety Lack of support from healthcare provider Others

3. Have you ever missed taking your medication? If yes, why?

4. How often do you visit your healthcare provider?

Every 3 months or more frequently Every 6 months to a year Less than once a year I don't have a regular healthcare provider

5. Which of the following barriers affect your ability to follow the prescribed treatment plan? (Select all that apply)

Difficulty understanding instructions Complex treatment regimen Lack of support from family/friends Transportation issues Language barriers Limited access to healthcare services Lack of motivation or commitment Other

6. Do you face any challenges in obtaining your medication? If yes, please specify.

7. How would you rate your overall satisfaction with your current healthcare provider?

Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied

8. Which of the following strategies have you used to help you remember to take your medication? (Select all that apply)

Setting reminders on phone or alarm Using pill organizers Asking a family member/friend to remind me Keeping medication visible as a reminder Using medication reminder apps None

9. What suggestions do you have to improve medication adherence?

10. Do you feel comfortable discussing any challenges with your healthcare provider?

Yes, always Yes, sometimes No, never

11. Which of the following support systems are available to you for managing medication adherence? (Select all that apply)

Family members Friends Online support groups/forums Local support groups None

12. Do you have any concerns regarding potential side effects of your medication? If yes, please explain.

13. How would you rate your understanding of your prescribed treatment plan?

Excellent Good Fair Poor

14. Which of these factors would support you in adhering to your medication? (Select all that apply)

Regular communication with healthcare provider Clear instructions about medication Simplified treatment regimen Access to educational resources Medication refill reminders Counseling or support services Reduced medication costs Others

15. What are the primary reasons for non-adherence to your medication?

16. Are you knowledgeable about the potential risks of non-adherence to your prescribed treatment?

Yes No

17. Which of the following would improve your experience in managing your medication adherence? (Select all that apply)

Simpler treatment regimens Improved packaging/labeling of medications Access to medication information in multiple languages Enhanced support from healthcare providers Incentives/rewards for adherence Mobile-based medication management tools Other

18. What challenges do you face in managing your medication on a daily basis?

19. Do you believe that adherence to your medication is important for your health outcomes?

Yes No

20. Which of the following resources would be helpful in improving your medication adherence? (Select all that apply)

Educational brochures Videos or animations explaining medication use Web-based medication management platforms Automated refill reminders Email/text message alerts Peer support programs Other