1.	I just forget to take my medicines some of the time.
	2.	I run out of my medicine because I don't get refills on time.
	3.	My use of alcohol gets in the way of taking my medicines.*
	4.	I worry about how medicine will affect my sexual health.
	5.	I sometimes forget things that are important to me.*
	6.	I have felt sad, down, or blue during the past month.*
	7.	I feel confident that each one of my medicines will help me.
	8.	I know if I am reaching my health goals.
	9.	I have someone I can call with questions about my medicines.
	10.	I understand my doctor's/nurse's instructions about the medicines I take.
	11.	My doctor/nurse and I work together to make decisions.
	12.	I am able to read and understand pill bottle labels.
	13.	Taking medicines more than once a day is inconvenient.
	14.	I have to take too many medicines a day.
	15.	It is hard for me to swallow the pills I have to take.
	16.	Taken a medicine more or less often than prescribed?
	17.	Skipped or stopped taking a medicine because you didn`t think it was working?
	18.	Skipped or stopped taking a medicine because it made you feel bad?
	19.	Skipped, stopped, not refilled, or taken less medicine because of the cost?
	20.	Not had medicine with you when it was time to take it?

* May warrant further discussion with healthcare provider.

The response that you provide in the survey above will be collected by GlaxoSmithKline and combined with the survey responses of all others who complete this survey. GlaxoSmithKline will analyze your responses along with those of all the others who complete this survey. GlaxoSmithKline will use your responses to understand barriers to adherence to medicines. GlaxoSmithKline will not use your individual survey responses for its marketing use, nor will it sell or transfer the information that you provide to any other party for their own marketing use.

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