TABLE 1.

Suggested Checklist for Identifying Patients at High Risk for Medication Nonadherence

	Evidence-Identified Factors	Measures
Socio-demographic factors	Ethnicity	❏ Hispanic ❏ Non-Hispanic
	Race	❏ White ❏ African American ❏ Asian ❏Multiracial ❏ Other (Specify:________________________________ )
	Age	❏ Young (<39 years) ❏ Middle-aged (40–64 years) ❏ Old (65–74 years) ❏ Elderly (≥75 years)
	Education	❏ < High school ❏ High school graduate ❏ ≥High school
	Low income	Below 200% of federal poverty level? ❏ No ❏ Yes
	Acculturation	Language barrier? ❏ No ❏ Yes
		Immigration? ❏ No ❏ Yes (When?__________________ )
		Acculturation (e.g., follows U.S. practices)? ❏ No ❏ Yes
	Health insurance	Has health insurance? ❏ No ❏ Yes
		Has prescribed drug coverage? ❏ No ❏ Yes
	Living conditions	Working ≥2 jobs: ❏ No ❏ Yes
		❏ Married (or living with someone) ❏ Unmarried (or living alone)
Patient factors	Understanding of diabetes	❏ No ❏ Yes
	Experiencing diabetes symptoms	❏ No ❏ Yes (Specify:________________________________ )
	Comorbidities	1. 2. 3.
	Poor eyesight/hearing	Glasses? ❏ No ❏ Yes; Vision corrected? ❏ No ❏ Yes Hearing aids? ❏ No ❏ Yes; Hearing corrected: ❏ No ❏ Yes
	Cognitive function	How frequently does patient experience forgetfulness? ❏ Never ❏ Hardly ever ❏ Sometimes ❏ Often ❏ Always
	Emotional states (all that apply)	❏ Depression ❏ Anxiety ❏ Denial ❏ Fear ❏ Other (Specify:________________________________ )
	Coping skills	❏ Inadequate ❏ Adequate
	Trust in HCP	❏ No ❏ Yes
	Social support (all that apply)	❏ Spouse/partner ❏ Family ❏ Friend(s)
	In need of ancillary resources (e.g., dental care, pharmacy, or nutrition counseling)	Expressing need of ancillary resources? ❏ No ❏ Yes (Specify:________________________________ )
	Awareness/usage of ancillary resources	❏ Nutrition counseling ❏ Peer support ❏ Community outreach program (Specify:___________________ ) ❏ Other (Specify:___________________ )