Medication Adherence Survey
Find out honestly whether patients take their medication – and what gets in the way.
4 questions · 1 page · about 2 minutes to answer · fully editable after you start
Half of long-term medications are not taken as prescribed, and patients rarely volunteer that in the consulting room. This survey asks without judgment: how often doses get missed, and why – forgetting, side effects, cost, or feeling fine without them. The no-blame framing is what makes the answers honest.
The reasons matter more than the rate: forgetting wants reminders, side effects want a medication review, cost wants a cheaper equivalent. Each answer routes to a different fix.
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Page 1
About your medication routine
This survey asks how taking your medication has been going. Missing doses is very common and there are no wrong answers, so tell us what is really happening. It takes about 2 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.In the past month, how often did you miss a dose? (It is common - be honest.)*
- Never
- Once or twice
- Weekly
- Most days
Q2.When you miss doses, what is usually the reason?
- I forget
- Side effects
- Cost
- I feel fine without them
- The schedule is complicated
- I rarely miss doses
- Other…
Q3.How much do you agree?
| Disagree | Unsure | Agree | |
|---|---|---|---|
| I understand what each medication is for | |||
| The benefits are worth the downsides | |||
| I can afford my medications |
Q4.What would make taking your medication easier?
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