Do You have a Pill Problem? | South Coast Medical Center

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Behavioral Health Questionnaire

Do You Have A “Pill” Problem? Check the statements that apply to you.

	Has your doctor, spouse or anyone else ever expressed concern about your use of medication?
	Have you ever decided it was time for you to stop using your pills, only to find yourself later again taking them contrary to your earlier decision?
	Have you ever felt remorse or concern about your need for medication?
	Has your efficiency or ambition decreased since taking pills?
	Have you ever established an emergency supply to carry in your purse or pocket or to hide away in case of emergency?
	Have you ever been treated for excess use of either pills or alcohol?
	Have you ever changed doctors or drug stores for the purpose of maintaining your supply?
	Have you ever received the same pill from two or more physicians or druggists at approximately the same time?
	Have you ever been turned down for a refill?
	Have you ever taken the same mind- or mood- affecting medication for over a year only to find that you still have the same symptom?
	Have you ever told your physician which pill works best for you and which dosage and had him adjust the prescription to fit your recommendation?
	Have you ever used tranquilizing or sleeping medication for a period of months or years with no real improvement in the problem?
	Have you increased the dosage, strength or frequency of your medications over the past months or years?
	Is your medication quite important to you: e.g. do you worry about getting refills before running out?
	Do you become annoyed or uncomfortable when others talk about your use of medication?
	Have you or anyone else ever noticed a change of personality when you take your medication?
	Have you ever taken your medication as a preventative measure before you had the associated symptom?
	Have you ever been embarrassed by your behavior when under the influence of your medication?
	Do you ever sneak or hide to take your pills?
	Do you find it impossible to stop or to go for a prolonged period without your pills?