| Item | Yes (0) | No (1) | |
| 1. Do you sometimes forget to take your medication? | Yes (0) | No (1) | |
| 2. People sometimes miss taking their medication for reasons other than forgetting. Over the past 2 weeks, were there any days when you did not take your medication? | Yes (0) | No (1) | |
| 3. Have you ever cut back or stopped taking your medication without telling your doctor because you felt worse when you took them? | Yes (0) | No (1) | |
| 4. When you travel or leave home, do you sometimes forget to bring your medication? | Yes (0) | No (1) | |
| 5. Did you take all your medication yesterday? | Yes (1) | No (0) | |
| 6. When you feel like your symptoms are under control, do you sometimes drop taking your medication? | Yes (0) | No (1) | |
| 7. Taking medicine is a real inconvenience for some people. Do you ever feel hassled sticking to your treatment plan? | Yes (0) | No (1) | |
| 8. How often do you have difficulty remembering to take your medication? Never/Rarely…………………0 Once in a While……………..1 Sometimes……………………2 Usually……………………….3 All the Time………………….4 | |||