This form is for research purposes only and is entirely confidential. Please do not provide your name. Thank you.

The following questions ask you about your beliefs, about your medicine, and about your health. Based on your answers, a behavioral psychologist will offer you individualized tailored suggestions about ideas to think about so that you can make the best decisions for your health and about your medication (if you provide an e-mail address in order for us to contact you). For example, questionare results might place you into a known category of anxiety sufferer where particular situations (e.g., having to be assertive with an authority figure) leave you vulnerable to panic attacks. Alternatively, you may be a person who is not up to date when it comes to current medical knowledge and thus, are making decisions about your health which are outdated. After identifying problem areas we can then offer behavioral strategies which patients similar to you have found valuable.

If you wish to receive feedback on your answers, please provide your e-mail address below. By providing your address you allow us to give you direct feedback on your answers. Under no conditions will your address be used for any purpose other than providing an assessment of the answers you gave to this questionaire.

E-mail address (optional):

Please answer the following questions as truthfully as possible. Give only one answer to each question unless otherwise instructed.

1. What is your ethnicity?

   	Caucasian
   	African-American
   	Asian
   	Hispanic
   	Other

2. Age:
3. Gender:
   Male Female
4. Medications:
   

   For what condition(s) do you take medications?	What medication do you take?	How long have you taken medication for this condition?

5. In total, how many prescription pills are you supposed to take every day (this means total pills, not how many different types of medication)?

   0 (none)	11 or 12
   1 or 2	13 or 14
   3 or 4	15 or 16
   5 or 6	17 or 18
   7 or 8	19 or 20
   9 or 10	21 or more pills a day

6. If you ever fail to take your medication at the prescribed time, what are the reasons (select all that apply)?
   I just did not remember
   I was trying to save money; I did not want to use up my prescription.
   I did not have any of my pills with me when it was time for me to take them.
   Skipping an occasional does doesn't really matter.
   I do not like taking medication, so sometimes I just skip taking it.
   I was just too busy.
   I take so many medications that sometimes I don't remember to take one of them.
   Other:
7. Have you ever been diagnosed by a physician with any of the following conditions (fill in all that apply)?
   Heart attack
   High cholesterol
   Heart disease, such as angina
   Hypertension (high blood pressure)
   Stroke
   Diabetes
   Asthma
   Arthritis
   Depression
   Anxiety
8. Which statement below best describes how you have taken your prescription medication over the past month?
   Exactly as prescribed
   Missed one dose
   Missed two or three doses
   Missed three to seven doses
   Missed more than seven doses
   Did not take at all
   
9. Have you ever had a problem with side effects from any medication you have taken?
   No
   Once, I had minor problems
   Once, I had serious problems
   More than once, I had minor problems
   More than once, I serious problems
10. In general, how would you rate your health over the past year?
    Excellent
    Very good
    Good
    Fair
    Poor
11. Does your health limit you in moderate activities such as cleaning the house or climbing several flights of stairs?
    A lot
    A little
    None, not at all
12. In the past month, how much has pain interfered with your normal work or taking care of your home?
    A lot
    A little
    None, not at all
13. How often in the past month have you felt downhearted and blue?
    All the time
    Most of the time
    Some of the time
    Not at all
14. How many times have you been hospitalized in the last two years?
    More than once
    Once
    Never

1. I sometimes skip doses of my medicine when I think my symptoms are under control.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
2. Even though I mean to take my medication as directed, for one reason or another, I don't stay on the proper schedule.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
3. Because I am worried about the long-term effects of my medication, I do not always take it as directed.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
4. It is not fair that I have this medical problem.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
5. I know I'll never be cured but I can manage my illness.
   Strongly agree
   Mildly agree
   Mildly disagree
   Strongly disagree
6. My health can be improved if I take control of it. Ultimately, it is up to me.
   Strongly agree
   Mildly agree
   Mildly disagree
   Strongly disagree
7. I am completely convinced that taking my medication exactly as prescribed will improve my health.
   Strongly agree
   Mildly agree
   Mildly disagree
   Strongly disagree
8. The out of pocket money that I spend on my medication puts a strain on my budget.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
9. I am the kind of person who prefers alternative medical approaches like herbal remedies or homeopathy to traditional western medicine.
   Strongly disagree
   Mildly disagree
   Mildly agree
   Strongly agree
10. I trust myself to remember always to take my pills the way I am supposed to.
    Strongly agree
    Mildly agree
    Mildly disagree
    Strongly disagree
11. I am confident that my doctor and I work well together as a team.
    Strongly agree
    Mildly agree
    Mildly disagree
    Strongly disagree
12. For the most part, I take my medication exactly the way my physician wants me to.
    Strongly agree
    Mildly agree
    Mildly disagree
    Strongly disagree
13. Below are a variety of graphs. Please indicate which one most closely resembles your history of medication compliance, i.e., how well you followed your doctor's orders regarding your medications.
    
    A
    B
    C
    D
    E
    F
    None of the above