Health Care Provider Survey Please indicate which title best describes you by circling the most appropriate title: Primary Care Physician’s Pharmacist Nurse Specialty Dr (please specify) (please specify): Physician Assistant DIRECTIONS: Please circle the best response for each question. Please select only 1 response. About how frequently are providers in your community asked to Nearly Several Several times Almost Q1 address a patient's pain management concerns during an average Rarely Everyday a week a month Never work week? If a patient presents with pain concerns, how likely are providers to Somewhat Neither likely Somewhat Q2 suggest an over-the-counter pain medication such as ibuprofen or Very likely Very unlikely likely nor unlikely unlikely acetaminophen? (as the first option) If a patient presents with pain concerns, how likely are providers to Somewhat Neither likely Somewhat Q3 Very likely Very unlikely prescribe an opioid pain killer? (as the first option) likely nor unlikely unlikely Q4 When prescribing opioid pain killers to a patient… how likely are providers to inquire about the patient’s Somewhat Neither likely Somewhat … Q4a Very likely Very unlikely past opioid use? likely nor unlikely unlikely how likely are providers to inquire about any past … Somewhat Neither likely Somewhat Q4b problems the patient may have with substance use or Very likely Very unlikely likely nor unlikely unlikely addiction? how likely are providers to review the patient's Somewhat Neither likely Somewhat … Q4c Very likely Very unlikely for previous opioid prescriptions? likely nor unlikely unlikely ... how likely are Doctors to check the Prescription Drug Somewhat Neither likely Somewhat Q4d Monitoring data base for previous opioid prescriptions Very likely Very unlikely likely nor unlikely unlikely given to the patient? ... how likely are other providers to check the Somewhat Neither likely Somewhat Q4d Prescription Drug Monitoring data base for previous Very likely Very unlikely likely nor unlikely unlikely opioid prescriptions given to the patient?
Health Care Provider Survey Please indicate which title best describes you by circling the most appropriate title: Primary Care Physician Physician’s Assistant Pharmacist Nurse Specialty Dr (please specify) (please specify): DIRECTIONS: Please circle the best response for each question. Please select only 1 response. Q1 About how frequently are providers in your community asked to address a patient's pain management concerns during an average work week? Nearly Everyday Several a week Several times a month Rarely Almost Never Q2 If a patient presents with pain concerns, how likely are providers to suggest an over-the-counter pain medication such as ibuprofen or acetaminophen? (as the first option) Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q3 If a patient presents with pain concerns, how likely are providers to prescribe an opioid pain killer? (as the first option) Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q4 When prescribing opioid pain killers to a patient… Q4a … how likely are providers to inquire about the patient’s past opioid use? Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q4b … how likely are providers to inquire about any past problems the patient may have with substance use or addiction? Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q4c … how likely are providers to review the patient's for previous opioid prescriptions? Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q4d ... how likely are Doctors to check the Prescription Drug Monitoring data base for previous opioid prescriptions given to the patient? Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely Q4d ... how likely are other providers to check the Prescription Drug Monitoring data base for previous opioid prescriptions given to the patient? Very likely Somewhat likely Neither likely nor unlikely Somewhat unlikely Very unlikely
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