Medication Risk Questionnaire

Research has shown that your age, the number of different medicines you take, and certain medicines may increase your risk for problems from your medicines. Answer the questions below, then click on “Get Results” to see what you can do to reduce your risk for medicine-related problems.

Note: All "Yes or No" questions must be answered, any individual medications you would like to select, and your age.

  1. Do you currently take five or more prescription medicines?  Yes  No
  2. Check any of the following medications that you may be taking:
    For Diabetes
    •  Insulin
    •  Diabinese® (chlorpropamide)
    •  Glucotrol® (glipizide)
    •  Diabeta®, Micronase®, Glynase® (glyburide )
    •  Glucophage®, Fortamet®, Glumetza®, Riomet® (metformin)
    Blood Thinners
    •  Coumadin® (warfarin)
    Other
    •  Tegretol® (carbamazepine)
    •  Lanoxin® (digoxin)
    •  Lithobid®, Lithonate®, Eskalith® (lithium)
    •  Dilantin® (phenytoin)
    •  Quinaglute®, Quinidex® (quinidine)
    •  Theo-24®, Theocron®, Elixophyllin®, Uniphyl® (theophylline )
  3. Does more than one physician prescribe medications for you on a regular basis?  Yes  No
  4. Do you sometimes forget to take one or more of your medicines?  Yes  No
  5. Do you sometimes choose not to take a medicine?  Yes  No