| 1. | Do you sometimes forget to take your pills? | Yes | No |
| 2. | People sometimes miss taking their medications for reasons other than forgetting. Thinking over the past two weeks, were there any days when you did not take your medicine? | ||
| 3. | Have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? | ||
| 4. | When you travel or leave home, do you sometimes forget to bring along your medicine? | ||
| 5. | Did you take all your medicine yesterday? | ||
| 6. | When you feel like your symptoms are under control, do you sometimes stop taking your medicine? | ||
| 7. | Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? | ||
| 8. | How often do you have difficulty remembering to take all your medicine? |