16A.Medication Name (not entered) 16B.Medication Code ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 16C.Formulation Pills Pills Pills Pills Pills Pills Pills Inhaler Inhaler Inhaler Inhaler Inhaler Inhaler Inhaler Nebulizer Nebulizer Nebulizer Nebulizer Nebulizer Nebulizer Nebulizer Liquid Liquid Liquid Liquid Liquid Liquid Liquid Suppository Suppository Suppository Suppository Suppository Suppository Suppository Injection Injection Injection Injection Injection Injection Injection Other Other Other Other Other Other Other 16D.Is the Medicine taken on most days, or just when Most Days Most Days Most Days Most Days Most Days Most Days Most Days you have symptoms, or Symptoms Symptoms Symptoms Symptoms Symptoms Symptoms Symptoms both? Both Both Both Both Both Both Both (If ‘most days’ ask Q16E, if ‘symptoms’ ask Q16F, if ‘both’, Other Other Other Other Other Other Other ask both Q16E and Q16F.) 16E. When you are taking the medication, how many __days/week ______days/week ______days/week ______days/week ______days/week ______days/week ______days/week days a week do you take it? 16F. When you are taking 0-3 0-3 0-3 0-3 0-3 0-3 0-3 the medication, how many 4-6 4-6 4-6 4-6 4-6 4-6 4-6 months in the past 12 7-9 7-9 7-9 7-9 7-9 7-9 7-9 months have you taken it? 10-12 10-12 10-12 10-12 10-12 10-12 10-12
16A.Medication Name (not entered) 16B.Medication Code ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 16C.Formulation Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other Pills Inhaler Nebulizer Liquid Suppository Injection Other 16D.Is the Medicine taken on most days, or just when you have symptoms, or both? (If ‘most days’ ask Q16E, if ‘symptoms’ ask Q16F, if ‘both’, ask both Q16E and Q16F.) Most Days Symptoms Both Other Most Days Symptoms Both Other Most Days Symptoms Both Other Most Days Symptoms Both Other Most Days Symptoms Both Other Most Days Symptoms Both Other Most Days Symptoms Both Other 16E. When you are taking the medication, how many days a week do you take it? __days/week ______days/week ______days/week ______days/week ______days/week ______days/week ______days/week 16F. When you are taking the medication, how many months in the past 12 months have you taken it? 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12 0-3 4-6 7-9 10-12