The Smart Medicine Organizer Consumer Survey
Thank you for participating in this survey!
I am answering this survey on behalf of:
Myself
A person I'm caring for
The following number of medicines and supplements are used by myself or the person I'm caring for:
1-3
4-6
7-10
11-14
15+
On a scale of ONE to SEVEN, how INFORMED do you feel about the special characteristics of your or a loved one’s medicines, such as indication, therapy goals, precautions, monitoring parameters, side effects, interactions, risks and benefits.
*
1 Extremely UNINFORMED
2
3
4
5
6
7 Extremely INFORMED
How HELPFUL do you believe the Smart Medicine Organizer would be for yourself or a loved one in facilitating an understanding of a medicine's special characteristics?
*
1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
How HELPFUL do you believe the Smart Medicine Organizer would be for yourself or a loved one in organizing medicines for proper administration and for preventing the duplication or omission of doses?
*
1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
If you were using the Smart Medicine Organizer for yourself or a loved one, which of the following options best describes how you’d complete the pull-out template:
*
I'd complete it electronically.
I'd complete it by hand.
I'd complete it by hand and electronically.
How COMFORTABLE would you be completing the pull-out template WITHOUT direct supervision from a healthcare provider,such as a physician, nurse practitioner, physician’s assistant, pharmacist or nurse (meaning you’d rely on information discussed during appointments, visits with your pharmacist, info that comes with the medicine from the pharmacy, and/or from a trustworthy drug book or website)?
*
1 Extremely UNCOMFORTABLE
2
3
4
5
6
7 Extremely COMFORTABLE
What is the LIKELIHOOD you’d obtain services from a pharmacist or similar healthcare provider, such as Medication Therapy Management services involving a comprehensive review of prescribed medicines and any supplements, or those of someone you care for, to obtain direct supervision for setting up the organizer and completing the pull-out template (assume an initial out-of-pocket cost of $65)?
*
1 Extremely UNLIKELY
2
3
4
5
6
7 Extremely LIKELY
If you selected SIX (6) or below to the previous question, and your health insurance would pay for the cost of such services, would your response change?
*
YES
NO
If you answered "YES" above, what would your new response be?
*
2
3
4
5
6
7 Extremely LIKELY
Not Applicable -I answered "NO" to the previous question.
How INTERESTED would you be in a service where your current therapy information is automatically integrated with the pull-out template, as communicated electronically from the healthcare provider or pharmacy, whereby electronic screening for potential interactions between medicines, food and any supplements may occur, and where some parts of the pull-out template may be automatically completed for printing based on peer-reviewed medical guidelines and current FDA safety data?
*
1 Extremely UNINTERESTED
2
3
4
5
6
7 Extremely INTERESTED
How COMFORTABLE would you be using a tablet computer instead of a piece of paper as the pull-out component that slides into the organizer, whereby the pull-out template information may be electronically completed and updated through an internet connection?
1 Extremely COMFORTABLE
2
3
4
5
6
7 Extremely UNCOMFORTABLE
It’s estimated that the cost of the Basic version of the Smart Medicine Organizer will be $54.95 and that the Deluxe version will be $64.95. How LIKELY would you be to purchase the Basic or Deluxe version for yourself or a loved one?
*
1 Extremely UNLIKELY
2
3
4
5
6
7 Extremely LIKELY
Thank you for taking the time to complete this survey!
Your individual survey responses may be combinedwith other participant responses for statistical analysis and publication in peerreviewed medical journals, e.g. Journal of the American Medical Association(JAMA). The personal information youprovide below will be kept confidential and will not be shared with any thirdparties except those exclusively entrusted with validating the survey results.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My age is:
*
18-34
35-55
56-70
71-85
86 or older
The age of the person I'm caring for is:
*
18-34
35-55
56-70
71-85
86 or older
Not applicable
My primary language is:
English
Spanish
Other
Do you wish to be contacted by Cardinal Support LLC?
Yes, I’m interested in purchasing the Deluxe Model of the organizer for myself or a loved one, please contact me if it becomes available.
Yes, I’m interested in purchasing the Basic Model of the organizer for myself or a loved one, please contact me if it becomes available.
Yes, I’m interested in sponsoring the organizer through a site like Kickstarter.com.
No, I’m not interested in the organizer and am only providing my information to establish the validity of any survey results presented in peer-reviewed medical journals. Thank you.
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