Medication Risk Questionnaire > CMHA > Center for Medicines and Healthy Aging

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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 "Next" to see what you can do to reduce your risk for medicine-related problems.

1. Do you currently take five or more prescription medicines?	Yes No
2. Do you take any of the following medications?	Yes No
For Diabetes
3. insulin	Yes No
4. Diabinese® (chlorpropamide)	Yes No
5. Glucotrol® (glipizide)	Yes No
6. Diabeta®, Micronase®, Glynase® (glyburide )	Yes No
7. Glucophage®, Fortamet®, Glumetza®, Riomet® (metformin)	Yes No
Blood Thinners
8. Coumadin® (warfarin)	Yes No
Other
9. Tegretol® (carbamazepine)	Yes No
10. Lanoxin® (digoxin)	Yes No
11.Lithobid®, Lithonate®, Eskalith® (lithium)	Yes No
12. Dilantin® (phenytoin)	Yes No
13. Quinaglute®, Quinidex® (quinidine)	Yes No
14.Theo-24®, Theocron®, Elixophyllin®, Uniphyl® (theophylline )	Yes No
15. Does more than one physician prescribe medications for you on a regular basis?	Yes No
16. Do you sometimes forget to take one or more of your medicines?	Yes No
17. Do you sometimes choose not to take a medicine?	Yes No
Enter the year you were born and your age.	Year Born Your Age