Medication Study Consent and Experience

Your Details and Consent

1. Thank you for considering our medication study. This form records your consent and asks about your health and your experience with the medication.

2. What is your full name?

   Open answer

3. In what year were you born?

   A number from 1900 to 2010

4. Do you agree to take part in this medication study?

   Choose one:

   • Yes
   • No

Your Medical History

Condition: Only for participants who consent

1. Have you been diagnosed with any of these conditions? Select all that apply.

   Choose any that apply:

   • Heart disease
   • Diabetes
   • Asthma
   • Epilepsy
   • Other
   • None of these

2. Please give details of the conditions you selected, including any other condition.

   Condition: Shown when at least one condition was selected

   Open answer

3. Have you ever had an allergic reaction to a medicine?

   Choose one:

   • Yes
   • No
   • Not sure

4. Which medicine caused the reaction, and what happened?

   Condition: Shown when an allergic reaction was reported

   Open answer

Medication You Use Now

Condition: Only for participants who consent

1. Which forms of medication are you using at the moment? Select all that apply.

   Choose any that apply:

   • Tablets or capsules
   • Injections
   • Skin patches
   • Inhalers
   • Eye drops
   • Other
   • None

2. List any other medicines or supplements you take that we should know about.

   Open answer

Your Experience with the Medication

Condition: Only for participants who consent

1. On a scale from 1 to 10, how satisfied are you with each aspect of the study medication?

   • How well it works
   • How well you tolerate it (side effects)
   • How easy it is to take

   For each row: choose one:

   • 1 - Very dissatisfied
   • 2
   • 3
   • 4
   • 5
   • 6
   • 7
   • 8
   • 9
   • 10 - Very satisfied

2. How much do you trust our medicines?

   A number from 0 to 5:

   • 0
   • 1
   • 2
   • 3
   • 4
   • 5

3. Is there anything else you would like to tell us about the medication?

   Open answer