Date *

MM

DD

YYYY

Name *

First Name

Last Name

1. Do you ever forget to take your medication? *

Yes

No

2. Are you careless at times about taking your medication? *

Yes

No

3. When you feel better, do you sometimes stop taking your medication? *

Yes

No

4. Sometimes if you feel worse when you take the medication, do you stop taking it? *

Yes

No

5. I take my medication only when I’m sick. *

Yes

No

6. It is unnatural for my mind and body to be controlled by medication. *

Yes

No

7. My thoughts are clearer on medication. *

Yes

No

8. By staying on medication, I can prevent getting sick. *

Yes

No

9. I feel weird like a “zombie” on medication. *

Yes

No

10. Medication makes me feel tired and sluggish . *

Yes

No