Self Assessment Form for Dosette Box

Do you have any routines to help you remember to take or use your medicines? *

Yes No

Do you have a medicine box at home that you fill with your daily medications? *

Yes No

Do you have any problems with opening or closing medicine containers? *

Yes No

DO YOU HAVE ANY PROBLEMS GETTING MEDICINES OUT OF CONTAINERS? *

Yes No

DO YOU TAKE OR USE ALL OF YOUR MEDICINE ACCORDING TO THE INSTRUCTIONS? *

Yes No

CAN YOU READ THE INSTRUCTIONS ON YOUR MEDICINE PACKET? *

Yes No

DO YOU KNOW WHAT YOU TAKE YOUR MEDICINE FOR ? *

Yes No

DO YOU SOMETIMES FORGET TO TAKE YOUR MEDICINES? *

Yes No

DOES ANYONE HELP YOU MANAGE DAILY TASKS(EG.WASHING) *

Yes No

WHICH MEDICINES DO YOU ONLY TAKE WHEN YOU NEED THEM RATHER THAN AS REQUIRED? *

WHO COULD GIVE YOU MORE HELP MANAGING YOUR MEDICINES? *

I CONFIRM THAT THE INFORMATION PROVIDED IS TO THE BEST OF MY ABILITY *

Yes No

PATIENTS NAME *

DATE OF BIRTH *

Further Information