Do you currently take 5 or more medications (on a regular basis)?

Yes No

Do you take 12 or more medication doses each day?
Hint: Add up the number of times a day that you take each of your medicines.
For example: a medicine that you take 3 times a day = 3 doses; a medicine you take once a day = 1 dose; 3+1=4 doses

Yes No

Do you take any of the following medications?

Yes No

Does more than one physician prescribe medications for you on a regular basis?

Yes No

Are you currently taking medications for 3 or more medical problems?

Yes No

Do you get prescriptions filled at more than one pharmacy?

Yes No

Does someone else bring any of your medications to your home for you?

Yes No

Have your medications OR the instructions on how to take them been changed 4 or more times in the past year?

Yes No