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2015
January
M
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MTM
Acta MedComp Survey
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Exit Survey
You are invited to participate in
Acta Research
's survey on medication use. In this survey, you will be asked to complete a survey that asks questions about what kinds of medical conditions you have, how many medications you take, and how you take your medications. It will take approximately 10 minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Acta Research at
[email protected]
.
Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
How old are you?
Less than 18 years old
18 to 29 years
30 to 45 years
46 to 64 years
65 years or older
What gender are you?
-- Select --
Male
Female
How often do you see your doctor?
One or more times a week
Once a month
Once every few months
Once a year
Less than once a year
Do you have any of the following medical conditions?
High blood pressure
High cholesterol
Diabetes
Sleep disorder
Nutritional disorder
Other
How many different medications do you take every day?
1
2
3
4
5
6
7
More
Where do you get your prescription medications?
At a chain pharmacy like CVS, Walgreens, or Kroger
At a small neighborhood pharmacy
At the hospital pharmacy
Online or by mail order
Other
How do you learn about your medications?
By talking to my doctor
By talking to my pharmacist
Through my nurse or caregiver
By talking to friends or relatives
Through the internet
Other
How do you get on the internet?
On my phone
On my personal computer
At work
At the public library
Other
How often do you take your medications?
Exactly as my doctor tells me to
More than my doctor tells me to
Less than my doctor tells me to
Whenever I remember
Other
Thank you for your response! This pre-study survey will be used only for research purposes, and your information will not be shared. For more information, please visit
www.rxresearch-acta.com.
If you would like to participate in Acta Research’s paid clinical studies, please check the box below to have us contact you about these opportunities.
I agree to be contacted by Acta Research staff
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