Antibiotic Self-Medication Survey Form
This survey gathers insights on your experiences and attitudes regarding self-medication with antibiotics. Your responses are anonymous and will help inform future health education efforts.
How often do you use antibiotics without a prescription?
*
Never
Rarely (once a year or less)
Sometimes (2-3 times a year)
Often (4 or more times a year)
What are your main reasons for self-medicating with antibiotics? (Select all that apply)
*
Convenience
Previous experience with same symptoms
Advice from friends or family
Difficulty accessing healthcare
Cost of doctor visit
Other
Where do you usually obtain antibiotics for self-medication?
*
Pharmacy without prescription
Leftover from previous prescription
Friends or family
Online purchase
Other
For which conditions have you used antibiotics without a prescription? (Select all that apply)
*
Sore throat
Cold or flu symptoms
Fever
Urinary tract infection
Skin infection
Other
How confident are you in knowing when antibiotics are needed?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
How concerned are you about antibiotic resistance?
*
Not concerned
1
2
3
4
Extremely concerned
5
1 is Not concerned, 5 is Extremely concerned
Please indicate your agreement with the following statements:
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I always finish the full course of antibiotics.
1
2
3
4
5
I believe antibiotics help with viral infections.
6
7
8
9
10
I keep leftover antibiotics for future use.
11
12
13
14
15
I am aware of the risks of improper antibiotic use.
16
17
18
19
20
How do you usually decide the dosage and duration when self-medicating with antibiotics?
*
As per previous doctor’s advice
Based on information from the internet
Advice from friends or family
I decide myself
Other
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or above
If you have any additional comments or experiences regarding antibiotic self-medication, please share them below:
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