Medication Questionnaire

Instructions: Pick one of your medications at home. It can be over the counter or prescription. You can google the medication and go to the manufacturer’s website for detailed information. If you are not sure what medication to review use Tylenol or Motrin. Answer all of the questions in the questionnaire. We will discuss anything you may have learned during our in-person meeting. 

Medication questionnaire 

When managing medication it is important to be familiar with the drugs. This list will assist you in understanding the medication.  

• The reason for the drug  ________________________________________________________

• The medication's purpose  ______________________________________________________

• Administration method/route _____________________________________________________

• Rules around the medication (can it be taken with other medications, with food, not with alcohol, avoid the sun, and specific timing ________________________________________________________________

• When and for how long  should medication be taken ___________________________________________________________________________

• How will you know if the medication is working ______________________________________

• Common side effects  _________________________________________________________

• What to do if there is a side effect  _______________________________________________

• What if a dose is missed _______________________________________________________

• How to dispose of the medication  _______________________________________________

•  How much does the drug cost __________________________________________________