Self-Medication Risk Survey Form
Please complete this survey to help us assess common self-medication habits and associated risks. Your responses are anonymous and will be used for educational purposes only.
How often do you take medication without a healthcare provider’s prescription?
*
Never
Rarely
Sometimes
Often
Very Often
Which types of medications do you most commonly self-medicate with? (Select all that apply)
*
Pain relievers (e.g., acetaminophen, ibuprofen)
Cold or flu remedies
Allergy medications
Antibiotics
Vitamins or supplements
Other
What is the main reason you choose to self-medicate?
*
Convenience
Cost savings
Previous experience with the illness
Lack of access to healthcare
Other
How confident are you in your knowledge about the medications you use without a prescription?
*
Not confident at all
1
2
3
4
Extremely confident
5
1 is Not confident at all, 5 is Extremely confident
Have you ever experienced side effects or complications from self-medication?
*
Yes
No
Not sure
How likely are you to consult a healthcare provider before taking a new medication?
*
Very unlikely
1
2
3
4
Very likely
5
1 is Very unlikely, 5 is Very likely
Please indicate your agreement with the following statements about self-medication.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Self-medication can be risky.
1
2
3
4
5
Reading medication labels is important.
6
7
8
9
10
It is safe to use leftover medication.
11
12
13
14
15
I am aware of potential drug interactions.
16
17
18
19
20
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Please specify your gender.
Female
Male
Prefer not to say
Other
If you have any comments or suggestions about self-medication risks, please share them here.
Submit Survey
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