The Smart Medicine Organizer Assisted Living Home Manager Survey
Thank you for participating in this survey!
On a scale of ONE to SEVEN, how IMPORTANT is it that patients or their caregivers understand the special characteristics of their medicines, including indication, therapy goals, precautions,monitoring parameters, potential side effects, risks and benefits?
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1 Extremely UNIMPORTANT
2
3
4
5
6
7 Extremely IMPORTANT
How HELPFUL do you believe the Smart Medicine Organizer would be for patients or caregivers in facilitating an understanding of a medicine's special characteristics?
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1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
How HELPFUL do you believe the Smart Medicine Organizer would be for patients or caregivers in organizing medicines for proper administration and for preventing the duplication or omission of doses?
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1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
How CAPABLE do you believe patients or caregivers would be in setting up the organizer, including completion of the pull-out template by hand or electronically, based on information discussed during appointments, pharmacy visits and info provided with the medicines from the pharmacy or within an appropriate drug reference book or website?
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1 Extremely INCAPABLE
2
3
4
5
6
7 Extremely CAPABLE
What is the LIKELIHOOD you’d work with patients or caregivers directly in setting up the organizer and completing the pull-out template?
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1 Extremely UNLIKELY
2
3
4
5
6
7 Extremely LIKELY
What is the LIKELIHOOD you’d recommend services from a pharmacist or similarly trained healthcare provider, such as CMS approved Medication Therapy Management services that include a comprehensive review of prescribed medicines and any supplements, whereby a patient or caregiver might receive direct supervision for setting up the organizer and completing the pull-out template?
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1 Extremely UNLIKELY
2
3
4
5
6
7 Extremely LIKELY
How HELPFUL do you believe it would be for an electronic service to accompany the organizer so that some parts of the pull-out template can be completed automatically based on a patient’s current therapies, up-to-date medical guidelines and FDA safety data, and where screening for potential interactions between medicines, food and any supplements also occurs automatically?
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1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
How HELPFUL would it be to use 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 as through an internet connection?
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1 Extremely UNHELPFUL
2
3
4
5
6
7 Extremely HELPFUL
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 (neither including a tablet computer). How INTERESTED would you be in offering a version of the Smart Medicine Organizer to those patients or caregivers who are managing five or more medicines?
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1 Extremely UNINTERESTED
2
3
4
5
6
7 Extremely INTERESTED
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 inpeer reviewed medical journals, e.g. Journal of the American MedicalAssociation (JAMA). The personalinformation you provide below will be kept confidential and will not be sharedwith any third parties except those exclusively entrusted with validating the surveyresults.
Name
*
First Name
Last Name
Business Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Management Role
Do you wish to be contacted by Cardinal Support LLC?
Yes, I’m interested in purchasing the Basic and/or Deluxe Model of the organizer for use or resale at my location(s).
Yes, I’m interested in a display containing brochures for use at my location(s).
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 the survey results for potential use in peer-reviewed medical journals. Thank you.
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