| Q1: What body area did you recently have surgery on? |
| Neck |
| Back |
| Hand, wrist, or forearm |
| Elbow, arm, or shoulder |
| Hip |
| Knee |
| Foot or ankle |
| Q2: What is your age? |
| 18-25 |
| 26-35 |
| 36-45 |
| 46-55 |
| 56-65 |
| 65+ |
| Q3: Describe your gender. |
| Male |
| Female |
| Other: ________ |
| Q4: Were you prescribed opioids (ie, oxycodone, Percocet, Vicodin, etc) after surgery? |
| Yes |
| No |
| Q5: Where in your house do you keep your prescription opioids? |
| Describe: _______ |
| Q6: Is this location locked? |
| Yes |
| No |
| Q7: What do you do with your unused pain medication? |
| I hold on to them |
| Flush them down the toilet |
| Throw them in the trash |
| Take them to a medication drop-off location |
| Other: _______ |
| Q8: Are you concerned about any children, family members, or friends using your pain medication? |
| Yes |
| No |
| Q9: Do you know someone who has misused prescription opioids? |
| Yes |
| No |
| Q10: How serious of a problem do you think prescription drug misuse is to society? |
| Not serious |
| Somewhat serious |
| Very serious |
| Extremely serious |
| Q11: Have you ever attended a drug take-back event? |
| Yes |
| No |
| Q12: Where would be best for you to dispose of any opioids? Choose as many as you like. |
| At a local pharmacy |
| At my physician’s office |
| At a special collection event in my community |
| At a police department |
| At a fire station |
| At a municipal hazardous waste facility |
| Other: _______ |
