Psychoactive Medication Survey
This 13 question survey asks you to describe your experience of taking prescribed psychoactive drugs. The survey should not take more than 5 minutes to complete Please answer as openly as possible - your responses are
guaranteed to be confidential
. Your information will not be released and no personally identifiable information is collected.
If you would like to receive notification of the results once the survey period is complete, then please provide your e-mail address. Otherwise leave it blank. Once again, your e-mail address will not be used for any other purpose and will be confidential.
Your E-mail address
1
Which country are you a citizen of?
South Africa
Neighbouring States
United States of America
United Kingdom
Elswhere in Africa
Other
2
What is your household's monthly income?
Less than 1000 rand
Between 1000 and 2000 rand
Between 2000 and 4000 rand
Between 4000 and 6000 rand
Between 6000 and 10 000 rand
More than 10 000 rand
3
When were you taking prescribed psychiatric medication?
I stopped more than two years ago
I stopped between 12 and 24 months ago
I stopped between 6 and 11 months ago
I stopped in the last siz months
I am currently taking medication
I have never taken any psychiatric medication
4
For how long did you take the medication? If you are still taking it, how long have you been doing so?
More than two years
Between one and two years
Between 6 months and a year
Between 3 to 6 months
Between one and three months
I have recently begun taking medication
5
Who prescribed the medication to you?
My G.P.
A G.P. other than my regular doctor
A psychiatrist
They haven't been prescribed. I get them from a friend or other source.
6
Place a tick next to each category of medication you took or are still taking
Anti-depressant
Anti-anxiety
Anti-psychotic
Mood stabiliser
Sleeping tablet
I don't know what category of drug I'm taking
7
I know the trade name of the drug(s) I took or am currently taking (Eg Prozac, Haloperodol)
True
False
8
I know the possible side effects of the medication(s) I took or am currently taking.
Not at all
A know a few of them
I know quite a few of them
I have a good knowledge of them
I know all possible side effects
9
To what extent do you believe that these medications helped or are helping you.
They've made me feel worse
They've helped me slightly
They've helped me moderately
They've made a significant difference
They've had a very positive effect
I'm not sure if they have or haven't helped me
10
I experience or have experienced side effects of the medication I'm taking
Yes
No
I'm not sure
11
If you answered true the last question, please tick the statement that is most true of your experience of them
They haven't bothered me at all
They are a nuisance but I can cope with them
I am distressed about them but I put up with them
I am very negatively affected by them
They have such a negative effect on my life that I consider changing the medication
12
If you have experienced side effects, please use the box to desribe the most prominent ones.
13
Have you made use of counselling or psychotherapeutic services in addition to the medication.
I have attended a long term (longer than three months) therapy
I attended a few session with a counsellor or therapist
I have not had any counselling or therapy
Thank you for participating in this survey. Come back to www.psychotherapy.co.za over the next months and view the results and report. Once you click the submit button, your answers will be displayed to you. For your records you may print that page or just close the browser windon.
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