QUESTIONNAIRE: Survey of knowledge on safe medication use in relation to NonSteroidal Anti-inflammatory Drugs
-------------------------------------------------------------------------------------------------------------------------------------Explanation: Please answer all questions completely, and coincides most with your personal views. The gained
information from this survey will be useful in development of system which promote patients' knowledge on
medicine safety, and self-monitoring of ADRs.
Part 1 Baseline Information
Explanation: Please tick a box () or answer the following questions about you.
1. Sex
 Male
Female
2. Age …………………… years old
3. Education
 Primary school
 Secondary school
 Senior high school
 Diploma




4. Occupation
 Unemployed

 Agriculturist

 Self employed business

 Work as employee

 etc. (please specify) ………………………………
5. What is the average income per month?
 less than 5,000 Baht
 10,001 – 20,000 Baht
 more than30,000 Baht
Bachelor’s degree
Master’s degree
Doctor’s degree
Etc. (please specify) …………
Student/Academic
Private corporation
Government officer
State enterprise
 5,000 – 10,000 Baht
 20,001 – 30,000 Baht
 None
6. What is your health insurance?
 The Universal Coverage(Gold Card)
 Social security
 The Civil Servant Medical Benefits Scheme
 Self-pay
 Etc. (please specify) ………………………………
7. Do you have underlying disease?
 No
 Yes(please specify) ………………………………….…………………………………………
8. A history of drinking
 Never
 Yes, but I quit drinking…………… months ago
 I’m still drinking about ………………glasses/week
9. A history of smoking
 Never
 Yes, but I quit smoking…………… months ago
 I’m still smoking about ………………roll/day
10. Do you take vitamin supplements and herbal medicine? (except the products prescribed from the hospital)
 No
 Yes (please specify) ……………………………………………………………………………
Part 2 Information about NSAIDs
For the following questions: "this drug" means the Non-steroidal Anti-inflammatory drug that you are
using at this time.
“Adverse Drug Reactions (ADRs)” refers to abnormal symptoms that occur after using a
medicine, such as nausea, vomiting, rash, headache, constipation, diarrhea, stomach irritation,
blurred vision, drowsiness, dizziness, palpitations, dizziness, muscle pain, etc.
Explanation: Please tick a box () or answer the following questions about you. All responses in the survey will
be kept strictly confidential and will not affect your normal treatment.
1. When did you start using this drug?
Month…………………………… year……………….
2. How often you are taking this drug?
 Taking this drug everyday
 Never take this drug
 Taking this drug when have symptom
 Other.……………………….
3. Administration of this drug
 Times per day
 1 time/day
 Time
 2 times/day  3 times/day  Other …………
 Before meal  After meal  Anytime
4. Do you know, this drug is used for...?
No
 Other.…………
Yes (please specify) …………..…………..
5. Have you received any information about this drug before? And who provided to you?
 Name of medicine
physician
 Pharmacist
Nurse
have not received
 Indication of medicine
physician
 Pharmacist
Nurse
have not received
 Mechanism of action
physician
 Pharmacist
Nurse
have not received
 Administration
physician
 Pharmacist
Nurse
have not received
 What to do if miss a dose
physician
 Pharmacist
Nurse
have not received
 Important consideration to be aware of
physician
 Pharmacist
Nurse
have not received
 Adverse drug reactions
physician
 Pharmacist
Nurse
have not received
 Monitoring ADRs of medicine
physician
 Pharmacist
Nurse
have not received
 Management of side effects
physician
 Pharmacist
Nurse
have not received
 Drug interactions
physician
 Pharmacist
Nurse
have not received
 Foods and herbs to be careful of
physician
 Pharmacist
Nurse
have not received
 Other…………………
physician
 Pharmacist
Nurse
have not received
 Other…………………
physician
 Pharmacist
Nurse
have not received
6. What information about adverse drug reactions have you received from a healthcare professional?
 Effects on gastrointestinal system (Stomach and Intestines)
That is (please specify)…………………………………………………………………..
 Effects on cardiovascular system
That is (please specify)…………………………………………………………………..
 Effects on renal system
That is (please specify)……………………………..…..………………………………..
 Effects on skin system
That is (please specify)…………………………………………………………………..
 Other effects
That is (please specify)…………………………………………………………………..
7. Apart from receiving information from physician, pharmacist, or nurse, what are your additional
sources of information?(can select more than 1 item)
 Internet
 Pamphlet
 Leaflets
 Television
 magazine/Journal of medicine
 Newspaper
 Radio
 Asking a parent
 Asking a neighbor
 etc........................
Part 3 Attitudes towards receiving information about adverse drug reactions
Explanation: Please tick a box () or answer the following questions about your opinions.
Questions
1. You need to know about ADRs of medications
2. Being informed about ADRs may increase your anxiety
3. Physicians should have a role to inform you about ADRs
4. Receiving ADR information from healthcare professional
may be a waste of time
5. Pharmacists should play a direct role in providing ADR
information
6. Information about ADRs may help you to tell physicians
about any abnormal symptoms which occur
7. Information about ADRs may cause you to discontinue
medicines
8. Healthcare setting provide you insufficient knowledge of
ADRs
9. Provision of information from health professionals and
receiving information leaflets can improve your
knowledge about medicines
10. Receiving information leaflets may encourage you to
decrease your adherence
Strongly
agree
Agree
Not
sure
Disagree
Strongly
disagree
Questions
Strongly
agree
Agree
Not
Disagree
sure
Strongly
disagree
11. Information leaflets are an information source which can
help you to monitor ADRs and tell health professionals
about ADRs.
12. Information leaflets cannot improve your confidence about
safety when using medicines
13. Receiving an information leaflet the first time of using a
medicine is a necessity
14. You don’t need information leaflets for all medicines
15. Information leaflets that you have read were difficult to
understand
16. Information leaflets are not reliable information sources
for providing medicines information for you
17. You need to receive information leaflets which are
specifically for patients
18. If you receive a patient information leaflet, you are
confident you will thoroughly read that leaflet
Do you have any advice about the necessity of providing the safety information about drug to patient?
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“Thank you for answering this questionnaire”