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CST- Medication Survey
(It was necessary to reformat this survey to fit
the webpage, you may need to reformat if you copy it.)
HELLO, MY NAME IS _______________ (staff persons name) AND I
AM A (CONSUMER OR A FAMILY MEMBER) WHO WORKS WITH THE CONSUMER SATISFACTION TEAM
OF MONTGOMERY COUNTY.
Many consumers have told us about the problems they have with
medications and how they affect so many areas of their lives, some in a positive
way and some in a negative way.
We are asking you to share your opinion about medications with
us, because we value what you have to say.
This survey will take about 20 minutes. It is confidential; we
don’t need to write your name down.
We will combine everyone’s opinions and bring back copies of
the results to the site where we interviewed and we will all work together to
make changes that have been recommended.
Thank you.
Has someone from the CST interviewed you before about medication?
_____ yes _____ no
(If yes, please let person know that we cannot interview twice)
Developed by
The CST of Montgomery Co., Inc.
(610) 270-3685, Email: Watsons@cstmont.com
CONSUMER SATISFACTION TEAM OF
LANCASTER COUNTY
MEDICATION SURVEY
August 2000
INTRODUCTION
1. Date of Interview: _______________
2. Interview Site: ____________________________
3. Interviewer’s Name: _______________________
MEDICATION ASSESSMENT
5. Could you tell us when you first started taking psychiatric medication?
If you don’t remember exactly please make your best guess.
Month ________ Year ________
6. Would you tell me the names of all the medications you are taking for
your mental health issues, for seizures or for any physical health problems
you might have.
Please tell us about any medication you are taking not just those
prescribed by your Doctor. How often do you take each one? Note To Staff:
Give the client the list of medications and ask him/her
to read the name and number of the medication.
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code number |
how often* |
how much help1 |
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* Once a day, three times a day, twice a week
or other
1. Answer Code: 1 = A Lot, 2 = Some, 3 = Not At
All, 4 = Don’t Know, 5 = No Response
7. Are you taking any other medications that are not
on the list? If yes, could you tell us about them?
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medication name |
how often* |
how much help1 |
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* Once a day, three times a day, twice a week or other
1. Answer Code: 1 = A Lot, 2 = Some, 3 = Not At All, 4 = Don’t
Know, 5 = No Response
8. Are there any medications that you are not taking but you
think might help you if you did take them?
(1) Yes _______ (If Yes Go To Question 7a)
(2) No _______ ( Go To Question 8)
(3) Don’t know ________ (Go To Question 8)
7a. What are these medications: How would they help you?
________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
9. How often do you meet with your Psychiatrist (Note to
interviewer: this is only for mental health medication) to talk about your
medications?
(1) Once a week ______
(2) More than once a week ______
(3) Once every two weeks _______
(4) Once every three weeks _______
(5) Once a month _______
(6) Less than once a month _______
(7) No Response ____________
10. How long do these medication meetings with your
psychiatrist usually last?
(1) 5 minutes _____
(2) 10 minutes _____
(3) 15 minutes _____
(4) 30 minutes _____
(5) 45 minutes _____
(6) 1 hour ____
(7) more than 1 hour ____
(8) Other (specify) ________
(9) No Response ________
10. If it were entirely up to you, how often would you meet
with your psychiatrist to talk about your medications ?
(1) One a week
(2) More than once a week
(3) Once every two weeks
(4) Once every three weeks
(5) Once a month
(6) Less than once a month
(7) No Response
11. When you have a meeting with your psychiatrist to talk
about your medications do you have time to talk about everything you want
to?
(1) Always ______
(2) Most of the time _____
(3) Some of the time _____
(4) Never _____
(5) No Response ______
12. Is the information and instructions the psychiatrist
gives you about your medications clear and easy to understand?
(1) Always _______
(2) Most of the time _______
(3) Some of the time _______
(4) Never ______
(5) No Response ______
13. In the last month have you asked your psychiatrist to
change any of your medications or to increase or decrease the amount of
medication you are taking?
(1) Yes ______ (Go To 13A)
(2) No ______ (Go To Question 14)
(3) No Response ______ (Go To Question 14)
13a. If Yes, what happened? (Please check below)
(1) A change was made _________
(2) The psychiatrist explained why it might not be a good
idea to change_______
(3) The psychiatrist said no but did not explain why
________
(4) No Response ________
14. Do you have to have your blood tested because you are
taking certain medications?
(1) Yes ______ (Go to 14a)
(2) No ______ (Go To Question 15)
(3) No Response _______ (Go To Question 15)
14a. If yes, how often is your blood-tested ___________
14b. How do you feel about the blood test?
(1) The blood test doesn’t bother me ______ (Go to
Question 15)
(2) I don’t like the blood test _______ (Go to
Question 14c & 14d)
(3) I have mixed feelings about the blood test _______
(Go to Question 14c & 14d)
(4) No Response ________ (Go to Question 15)
14c. Since you don’t like the blood test would you rather,
Continue with the blood test because the medication is
so much help ____
Change to another medication that does not require a
blood test even if the new medication would not help me as much as the
one I am taking now ______
No Response ________
14d. Why don’t you like to have a blood test?
__________________________________
_________________________________________________________________
15. Are the medication(s) you are now taking causing you to
(check all that apply):
(1) Have dry mouth ______
(2) Gain weight _______
(3) Effecting your sex life _____
(4) Feel tired or sleepy _____
(5) Have difficulty sleeping _____
(6) Have a problem with your eyesight _____
(7) Have difficulty concentrating ____
(8) Be constipated _____
(9) Have diarrhea _____
(10) Have uncontrollable shaking in one or several parts of
your body ____
(11) Have headaches ______
(12) Have nausea _____
(13) Other (specify)
________________________________________________
16. Sometimes the side effects of my psychiatric medication
get so bad that I stop taking it.
(1) Yes _______
(2) No _______
(3) No Response _____
If Yes, What Usually Happens
______________________________________
17. Sometimes the side effects of my psychiatric medication
get so bad that I reduce the amount I’m taking.
(1) Yes _______
(2) No _______
(3) No Response ______
If Yes, What Usually happens
______________________________________
18. When I’m feeling good it’s OK to reduce the amount
of psychiatric medication I usually take without talking to my Doctor
(1) Yes _______
(2) No _______
(3) No Response _____
19. When I’m feeling bad it’s OK to increase the amount
of psychiatric medication I usually take without consulting my Doctor.
(1) Yes _______
(2) No ________
(3) No Response _____
20. In the last month I sometimes just forgot to take some
or all of my psychiatric medication(s).
(1) Yes ______
(2) No _______
(3) No Response _____
21. In the last month I sometimes didn’t take my
psychiatric medication because I just didn’t want to.
(1) Yes ______
(2) No _______
(3) No Response ______
22. Sometimes it’s hard to keep track of when to take my
medication(s).
(1) Yes ______
(2) No ______
(3) No Response ______
23. Sometimes it’s hard to keep track of how much
medication I should take.
(1) Yes ______
(2) No _______
(3) No Response ______
24. I would like to know more about how my psychiatric
medications are supposed to help me.
(1) Yes ______
(2) No ______
(3) No Response _____
25. I would like to know more about the side effects my
psychiatric medications can cause.
(1) Yes ______
(2) No ______
(3) No Response ______
26. I would like to learn about other psychiatric
medications that might help me.
(1) Yes ______
(2) No _______
(3) No Response ______
27. When I don’t take psychiatric medication I feel
better about myself.
(1) Yes ______
(2) No ______
(3) No Response _____
28. All things considered, I need to be taking my
psychiatric medications
(1) Yes ______
(2) No _______
(3) No Response _____
In No, please explain
_________________________________________
29. I would like to learn about other types of treatment
such as massage, acupuncture, yoga, aromatherapy, prayer and biofeedback.
(1) Yes _____
(2) No _____
(3) No Response _____
(4) Other ___________________________
30. Who prescribed the psychiatric medication(s) you are now
taking(check all that apply)
(1) My Family Doctor ______
(2) My Psychiatrist _______
(3) From Another Doctor (not the Family Doctor or
Psychiatrist)
(4) Other (specify) ______________________
31. Where do you now get your psychiatric medications?
(check all that apply)
(1) From My Family Doctor ______
(2) From My Psychiatrist ________
(3) From Another Doctor (not the Family Doctor or
Psychiatrist) ______
(4 From A Partial Hospital _______
(5 From The Community Treatment Team _____
(6) From One Drug Store _____
(7) From Different Drug Stores ______
(8) CRR
(9) Other (please specify) ______
32. Do you use any of the following to help control
symptoms? Please check all that apply.
(1) Alcohol _______ (3) Caffeine _______
(2) Street drugs ________ (4) Nicotine _______
33. When you get your psychiatric medications do you have to
pay something?
(1) Yes _____ (Go to question 33a)
(2) No ______ (Go to question 34)
(3) No Response ________ (Go to question 34)
33a. In the last 6 months have you ever gone without your
psychiatric medication because you can’t afford to pay for it?
(1) Yes ______ If yes, how often? _______
(2) No ______
(3) No Response _____
34. Do you feel that you are taking too much psychiatric
medication?
(1) Yes _______ If yes, for how long? ________________
(2) No _______
35. Do you feel that you are not taking enough psychiatric
medication?
(1) Yes _______ If yes, for how long? ________________
(2) No _______
36. In the last 6 months, have you ever been denied your
psych meds at a pharmacy?
(1) No _______
(2) Yes _______ If yes, please tell what
happened ___________________
____________________________________________________
____________________________________________________
____________________________________________________
37. In the last 6 months, have you ever had a delay in
receiving your psych meds at a pharmacy because they did not have a
prescription from your doctor or for some other reason?
(3) No _______
(4) Yes _______ If yes, please tell what
happened ___________________
____________________________________________________
____________________________________________________
____________________________________________________
38. In your own words please tell me what you think would
happen if you stopped taking your current psychiatric medication(s).
___________________________________________________________________________________________________________________________________________________________________________________________
39. Is there anything else you would like to tell us about
your medications ?
___________________________________________________________________________________________________________________________________________________________________________________________
DEMOGRAPHICS
Note to Interviewer - If people want to know why we
need this information it is because: people with different
characteristics
sometimes have different opinions and experiences with
medications. For instance, older people may have different mediation side
effects
than younger people. In order for us to accurately describe
the experiences and opinions of different groups of consumers we are asking
people
to provide us with some information about themselves.
B1. Age At Last Birthday _________
B2. Sex: (Circle Appropriate Answer) (1) Male (2) Female
B3. Race: ( Circle Appropriate Answer)
(1) White
(2) African American
(3) Asian/Asian American
(4) Pacific Islander
(5) Native American
(6) Mixed
(7) No Response
B4. Hispanic Origin (Circle Appropriate Answer)
(1) Yes
(2) No
(3) No Response
B5. Education Completed (Circle Appropriate Answer)
(1) 1- 8
(2) 9 - 12 (No Diploma)
(3) High School Graduate
(4) GED
(5) Some College
(6) Associates Degree
(7) Bachelors Degree
(8) Masters Degree
(9) Ph.D. or Equivalent (ScD, MD)
(10) No Response
CST Staff Observations
Staff Name: ____________________________________
Date: _____________________
Site Location: ____________________________________________
S1. Please comment regarding your individual site observations, which
can include, but not be limited to: safety issues, environmental
concerns, etc…
Please do this after you have left the site and remember that Sandy Watson
must be notified immediately of any reported abuse.
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