Medicine Use Survey Form
Please help us by answering the following questions about your recent medicine use. This survey does not collect sensitive or personal information.
What is your age range?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
What is your gender?
*
Female
Male
Non-binary
Prefer not to say
Other
Which country or region do you live in?
*
Please Select
United States
Canada
United Kingdom
Australia
India
Other
What is the main reason you use this medicine?
*
Pain relief
Chronic condition management
Infection
Allergy
Prevention
Other
What is the name or category of the medicine you use?
*
How often do you use this medicine?
*
Daily
A few times a week
Weekly
Monthly
As needed
What is the typical dosage or frequency you take?
*
How do you usually obtain this medicine?
*
Pharmacy (with prescription)
Pharmacy (over the counter)
Online
Friend or family
Other
Have you noticed any side effects?
*
No side effects
Mild side effects
Moderate side effects
Severe side effects
Not sure
How satisfied are you with the medicine's overall helpfulness?
*
1
2
3
4
5
Submit Survey
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