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

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