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Do you or someone in your immediate family regularly take prescription drugs for an illness or other ailment?
Yes
No
When filling a prescription for these medications, would you say that you are concerned about their price?
Yes
No
On a scale of 1 to 5, how much would you say you worry about being able to afford your prescription drugs?
1
2
3
4
5
Have you or someone in your family had to do any of the following to afford prescription drugs? (Check all that apply.)
Lowered their recommended dosage or spread out the supply of medication
Skipped meals or other expenses
Sold possessions of value
Dipped into retirement or other long-term savings accounts
If you answered yes on any of these previous questions, was the person using the prescription medication over the age of 65?
Yes
No
Does your health insurance help cover the cost of these medications?
Yes
No
Do you have a story or any other information about the cost of prescription drugs that you would like to share?