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. 2016 Jul 18;17:322. doi: 10.1186/s13063-016-1392-3

Table 5.

Regimen adherence questionnaire

1. How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than 2 hours before or 2 hours after the time your doctor told you to take it.
☐ All of the time
☐ Most of the time
☐ Rarely
☐ Never
2. On average, how many days per week would you say that you missed at least one dose of your HIV medications?
☐ Every day
☐ 4 to 6 days/week
☐ 2 or 3 days/week
☐ Once a week
☐ Less than once a week
☐ Never
3. When was the last time you missed at least one dose of your HIV medications?
☐ Within the past week
☐ 1 to 2 weeks ago
☐ 3 to 4 weeks ago
☐ Between 1 and 3 months ago
☐ More than 3 months ago
☐ Never