Home-Care Survey What are your attitudes, experiences, and habits regarding home-care? Question Title * 1. How old are you? Age (in years): Question Title * 2. Gender: Man Woman Question Title * 3. What is the highest level of education that you have completed? Some high school High school diploma / GED Some college / Associate's degree Bachelor's degree Post-graduate (i.e., Master's degree, Doctorate, etc.) Question Title * 4. What is your current occupation? Question Title * 5. What is your total household (if single, personal) income per year? Less than $25,000 $25,000 to $50,000 $50,000 to $75,000 $75,000 to $100,000 Greater than $100,000 Question Title * 6. Language (Check all that you are fluent) English Spanish Other (please specify) Question Title * 7. How often do you go to the doctor? Multiple times a month Approximately once a month Multiple times a year Approximately once a year Less than once a year Question Title * 8. What types of medications / medical devices have you used? We want to understand which of these you have administered to yourself or others. (Choose all that apply) Oral pills / liquids Injections (e.g., syringes, auto-injectors, injector pens, etc.) Infusion and other Wearable Devices (e.g., insulin pump, feeding pump, pacemaker, etc.) Other (please specify) Question Title * 9. If you use any wearable wellness tools or use mobile wellness apps, please tell us what you currently use (e.g., heart rate monitor for running, nutrition app on phone, etc.) Question Title * 10. How comfortable are you when using technology, like laptops, tablets, and cell phones? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 11. How comfortable would you be with administering oral medications that you DO NOT need to measure, such as pills, at home? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 12. How comfortable would you be with administering oral medications that you DO need to measure, such as liquid or suspension (powder/tablets you mix in water) medications, at home? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 13. How comfortable would you be with administering nasal or sprayable medications, including nebulizer-like products, at home? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 14. How comfortable would you be with administering topically applied medications, such as skin creams and gels, at home? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 15. How comfortable would you be with administering medication with an injection device, such as a syringe or auto-injector, at home? 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) 1 (Not at all comfortable) 2 3 4 5 (Very comfortable) Question Title * 16. Overall, how confident are you that you have received the correct medication and dose if it is administered by a healthcare professional? 1 (Not at all confident) 2 3 4 5 (Very confident) 1 (Not at all confident) 2 3 4 5 (Very confident) Question Title * 17. Overall, how confident are you that you have received the correct medication and dose if you administer it yourself, according to your doctor’s orders? 1 (Not at all confident) 2 3 4 5 (Very confident) 1 (Not at all confident) 2 3 4 5 (Very confident) Question Title * 18. If given the choice, would you prefer to go to the doctor to receive medication or administer the medication yourself at home? Go to the doctor Administer yourself Question Title * 19. In the past, when you had questions regarding how to use a medical device, what did you do first? Look at the instructions Go online and search for a solution Contact your doctor / pharmacist Contact the device manufacturer Trial and error until you figure it out on your own Ask a friend / family member for help Use a mobile device app Other (please specify) Question Title * 20. Ideally, if you had questions regarding how to use a medical device, where would you prefer to look first to find an answer? Look at the instructions Go online and search for a solution Contact your doctor / pharmacist Contact the device manufacturer Watch a video on how to use the device Receive in-person training on how to use the device Use a mobile device app Other (please specify) Question Title * 21. At what point would you seek professional assistance when using a medical device at home? (Choose all that apply) Before using the device for the first time If you have a question about how to use the device If you think you are not getting your full treatment If you are experiencing adverse side effects Never Question Title * 22. What would make you more comfortable with using medical devices to self-administer treatment at home? Question Title * 23. In the past, how did you usually remind yourself to take a medication that you had to take regularly (e.g., daily, weekly, twice a month, etc.)? Check all that apply. I have never had to take a medication regularly Wrote it on a physical calendar Put it on a digital calendar (e.g., Google calendar) WITHOUT a reminder Put it on a digital calendar (e.g., Google calendar) WITH a reminder Created an alarm on your phone (or similar device) Remembered on your own Other (please specify) Question Title * 24. Ideally, how would you like to be reminded to take a medication that you have to take regularly (e.g., daily, weekly, twice a month, etc.)? Check all that apply. Indicator on the device / medicine container Write it on a physical calendar Put it on a digital calendar (e.g., Google calendar) with or without a reminder Create an alarm on your phone (or similar device) Phone app to help you manage your medicine(s) Automated text / email reminder Other (please specify) Done
