None	A little	A lot
a.	My medication causes side effects	0	1	2
b.	It is hard to remember all the doses	0	1	2
c.	It is hard to pay for the medications	0	1	2
d.	The dosage times are inconvenient	0	1	2
e.	It is hard to open the bottle	0	1	2
f.	It is hard to get the drops in my eye	0	1	2
g.	Too many drops come out at the same time	0	1	2
h.	Drops fall on cheeks	0	1	2
i.	It is hard to squeeze the bottle	0	1	2
j.	My medication causes other problems or concerns	0	1	2
	If other problems or concerns explain:_____________________________________