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Conditions, Treatments & Drug Brands
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Conditions, Treatments & Drug Brands
Click each Condition below for details
Acid Reflux/GERD
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
ADD/ADHD
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Psychological Therapy/Counseling
Adult Acne
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Age Related Memory Loss
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Allergies/Allergic Reaction; Anaphylaxis
Experienced in Last 12 Months?
Type
Food Allergy (e.g., peanuts, shellfish)
Grass Allergy
Insect Allergy (e.g., bee stings)
Pet Allergy (e.g., cat/dog dander)
Ragweed Allergy
Tree Pollen Allergy
Have you ever experienced anaphylaxis?
Professionally Diagnosed (asked for: Allergies, Anaphylaxis)
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Anemia
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Anxiety
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Psychological Therapy/Counseling
Arthritis
Ever Experienced?
Type
Ankylosing Spondylitis
Osteoarthritis
Psoriatic Arthritis
Rheumatoid Arthritis
Other Arthritis
Professionally Diagnosed
Ankylosing Spondylitis
Osteoarthritis
Psoriatic Arthritis
Rheumatoid Arthritis
When diagnosed (asked for: Rheumatoid Arthritis)
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Severity
Treatments
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Medical Marijuana
Physical Therapy
Surgery
Satisfaction with Rx treatment (asked for: Osteoarthritis, Psoriatic Arthritis, Rheumatoid Arthritis)
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Feel at risk for?
Arthritis (Osteoarthritis)
Arthritis (RA/Rheumatoid Arthritis)
Asthma
Ever Experienced?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Severity:
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Athlete's Foot
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Bipolar Disorder
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Psychological Therapy/Counseling
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Blood clots in the legs (DVT); Pulmonary Embolism (PE)
Ever Experienced?
Have you ever experienced a pulmonary embolism (PE)?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Feel at risk for?
Blood Clots in the Legs (DVT)
Bronchitis
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Cancer
Ever Experienced?
Type
Breast
Colon/Colorectal
Head and Neck (including mouth, nose and throat)
Leukemia
Liver
Lung
Non-Hodgkin's Lymphoma
Ovarian
Pancreatic
Skin
Stomach
Urinary/Bladder/Kidney
Uterine/Cervical
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Stage of cancer at the time of diagnosis
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Don't know
Has/did the cancer spread to other locations?
Current stage of cancer treatment
Currently undergoing treatment for active cancer (e.g., chemotherapy, radiation)
Cancer is in remission but taking prescription medication to prevent recurrence
Cancer is in remission or cured and no longer treating
Treatments
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Blood Product Donation/Transfusion
Chemotherapy
ImmunoOncology/Immunotherapy
Medical Marijuana
Psychological therapy/counseling
Radiation
Surgery
Feel at risk for?
Cardiovascular/Heart Disease
Ever Experienced?
Type
Acute Coronary Syndrome/Heart Attack
Angina
Atrial Fibrillation (A-Fib)
Coronary Artery Disease
Professionally Diagnosed
When diagnosed (asked for: Atrial Fibrillation)
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Physical Therapy
Psychological Therapy/Counseling
Surgery
Feel at risk for?
Acute Coronary Syndrome/Heart Attack
Heart Disease
Cold
Experienced in Last 12 Months?
Treatments (Cold/Flu/Cough):
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Cold Sores/Canker Sores
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Constipation/Irregularity
Experienced in Last 12 Months?
"Is your constipation chronic (i.e., fewer than three bowel movements a week, persisting for several weeks or longer)?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Have you ever experienced constipation as a result of taking prescription medication for pain?
COPD (including Chronic Bronchitis and Emphysema)
Ever Experienced?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Oxygen Therapy
Physical Therapy
Psychological Therapy/Counseling
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Feel at risk for?
COPD (including Chronic Bronchitis and Emphysema)
Cough
Experienced in Last 12 Months?
Treatments (Cold/Flu/Cough):
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Depression
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Psychological Therapy/Counseling
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Diabetes; Diabetic Nerve Pain/Neuropathy
Ever Experienced?
Type:
Ever experienced diabetic nerve pain/neuropathy?
Professionally Diagnosed (asked for: Type 1, Type 2, Diabetic Nerve Pain)
When diagnosed (asked for: Type 2 Diabetes)
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Have you used a blood glucose meter in the last 30 days?
How many times per day, on average, do you use a blood glucose meter?
Less than once a day
1-2 times per day
3-5 times per day
6 or more times per day
Which of these blood glucose meters do you currently own?
Accu-Chek
Ascensia
Breeze
Contour
FreeStyle
iBGStar
OneTouch
TRUE
WaveSense
Other brand
Do not own a blood glucose meter
Which of the following diabetes-related complications or conditions have you ever experienced?
Cardiovascular/Heart conditions (e.g., Angina, heart disease)
DKA and ketones
Eye conditions (e.g., glaucoma, cataracts)
Foot conditions (e.g., ulcers, poor circulation, amputation)
Gastroparesis
Hearing impairment
Hypertension/High blood pressure
Kidney disease
Skin conditions (e.g., infections, itching)
Stroke
Have you had a hemoglobin A1c (HbA1c) test in the last 12 months?
What were your most recent hemoglobin A1c (HbA1c) test results?
4% - 5.6%
5.7% - 6.4%
6.5%+
7%+
Don't recall
How easy or difficult is it for you to maintain the A1c level recommended by your health care provider?
Very easy
Somewhat easy
Somewhat difficult
Very difficult
Treatments:
Type 1
Type 2
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Type 1
Type 2
Injections
Insulin
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Feel at risk for?
Eczema
Experienced in Last 12 Months?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Severity:
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Enlarged Prostate/Benign Prostate Hyperplasia
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Erectile Difficulty
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Psychological Therapy/Counseling
Surgery
Eye Problems/Eye Disease (including Dry Eye)
Experienced in Last 12 Months?
Type:
Cataracts
Dry Eye
Glaucoma
Macular Degeneration
Other eye problems or disease
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Medical Marijuana
Surgery
Fibromyalgia
Ever Experienced?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Physical Therapy
Flu
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments (Cold/Flu/Cough):
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Gas
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Gout
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Hair Loss
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Headache (non-migraine)
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Heartburn/Indigestion
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Hepatitis B
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Hepatitis C
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Herpes
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
High Cholesterol
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
HIV
Ever Experienced?
Professionally Diagnosed
Has Disease Progressed to AIDS?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Hyperhidrosis/Excessive Sweating
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Hypertension/High Blood Pressure
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Hypothyroidism
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Inflammatory Bowel Disease/IBD (including Crohn's and Colitis)
Ever Experienced?
Professionally Diagnosed
When diagnosed (asked for: Crohn's, Ulcerative Colitis)
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Severity:
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Irritable Bowel Syndrome (IBS)
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Kidney Disease
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Feel at risk for?
Low Testosterone
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Lupus (SLE)
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Feel at risk for?
Menopause
Ever Experienced?
Have you experienced any of the following as a side-effect or symptom of menopause?
Night Sweats
Dyspareunia (painful intercourse)
Hot Flashes
Vaginal Dryness
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Menstrual Cramps/PMS
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Migraine Headache
Experienced in Last 12 Months?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Are your Migraines Episodic or Chronic?
Episodic (occur occasionally)
Chronic (occur on 15 or more days in a month, with a headache lasting 4 hours or longer)
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Multiple Sclerosis
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Medical Marijuana
Physical Therapy
Nail Fungus
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Obesity
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Osteopenia
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Osteoporosis
Ever Experienced?
Professionally Diagnosed
When diagnosed
In the last 12 months
1 to less than 2 years ago
2 to less than 5 years ago
5 to less than 10 years ago
10 to less than 15 years ago
15 to less than 20 years ago
20 or more years ago
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Overactive Bladder
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Pain
Experienced in Last 12 Months?
Is any of the pain you experienced a symptom of any of the conditions below?
Ankylosing Spondylitis
Osteoarthritis
Psoriatic Arthritis
Rheumatoid Arthritis
Blood clots in legs (DVT)
Cancer
Diabetic Nerve Pain/Neuropathy
Fibromyalgia
Gout
Inflammatory Bowel Disease/IBD
Lupus (SLE)
Migraine Headache
Multiple Sclerosis
Restless Leg Syndrome (RLS)
Shingles
Type:
Back Pain
Head Pain
Joint Pain
Muscle Pain
Neck Pain
Nerve Pain
Other Pain
Severity on a typical day in past 12 months:
No Pain, 0
Mild Pain, 1-3
Moderate Pain, 4-6
Severe Pain, 7-10
Has the pain interfered with your ability to fall asleep or stay asleep at night?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Injections
Medical Marijuana
Physical Therapy
Surgery
Pneumonia
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Post Traumatic Stress Disorder (PTSD)
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Psychological Therapy/Counseling
Psoriasis
Ever Experienced?
Have you ever experienced psoriatic arthritis?
Professionally Diagnosed
Severity:
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Satisfaction with Rx treatment:
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Feel at risk for?
Restless Leg Syndrome (RLS)
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Rosacea
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Seizures/Epilepsy
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Shingles
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Feel at risk for?
Sinus Congestion/Sinus Headache
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Sleeping Difficulty/Insomnia; Sleep Apnea
Experienced Sleeping Difficulty/Insomnia in last 12 months?
Experienced Sleep Apnea in last 12 months? (NOTE: No other questions asked for Sleep Apnea.)
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Psychological Therapy/Counseling
Stroke
Ever Experienced?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Treatments - Condition Specific
Feel at risk for?
Tired/Run Down Feeling
Experienced in Last 12 Months?
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Urinary Tract Infection
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Feel at risk for?
Yeast Infection
Experienced in Last 12 Months?
Professionally Diagnosed
Treatments:
Non-Prescription Drugs
Prescription Drugs – Brand Name
Prescription Drugs – Generic
Diet or Exercise
Herbal or Home Remedy
Vitamins/Supplements
Other Treatment
Not Treating
Click each Item or Condition below for details
Use of Rx and Non-Rx Drugs
How often do you take non-prescription drugs (including aspirin) at the same time you take prescription medication?
Very often
Often
Sometimes
Never
Add-on Treatment
Sometimes a single prescription medication may not work as well as expected for treating of a particular health condition. In certain cases, taking a second or “add-on” prescription medication can improve symptoms or accelerate the response to treatment. Would you consider taking a second or add-on medication?
Definitely would not
Probably would not
Probably would
Definitely would
Currently taking an “add-on” Rx medication
General Drugs
OTC - First Aid Products & Topical Remedies
A+D
Bacitracin
Bactine
Band-Aid Adhesive Bandage
Band-Aid Liquid Bandage
Benadryl (Itch Stopping)
Caladryl
Calamine Lotion
Campho-phenique Liquid
Cortizone-10
Gold Bond Cream
Hydrogen Peroxide
Neosporin
Orajel
Polysporin
Preparation H
Generic/Store brand
Other non-prescription
OTC - Pain
Advil
Advil PM
Aleve
Bayer Aspirin
Bufferin
Excedrin
Extra Strength Bayer Back & Body Pain
Extra Strength Bayer Plus
Motrin IB
Tylenol
Tylenol 8 Hour
Tylenol Extra-Strength
Tylenol PM
Generic/Store brand
Other non-prescription
OTC - Pain Relieving Rubs & Liquids
Aspercreme
Bengay
Flector patch
Flexall
Icy Hot
Sportscreme
ThermaCare
Generic/Store brand
Other non-prescription
RX - Infections/Antibiotics
Amoxicillin
Augmentin
Avelox
Biaxin
Ceftin
Cefzil
Cipro
Rocephin
Zithromax
Generic prescription
Other prescription
Vitamin/Mineral Supplements
Which of the following reasons describe why you used a vitamin/mineral supplement in the last 12 months?
Additional nutrients
Bone health
Digestive health
Healthy aging
Heart health
Immune health
Increased energy
Joint health
Overall health/wellness benefits
Weight management
Other reasons
TYPES of Vitamin/Mineral Supplements
Calcium
Fiber
Folic acid (vitamin B9)
Glucosamine
Herbals/Botanicals (e.g., turmeric, green tea, melatonin)
Iron
Magnesium
Multi-vitamin
Niacin (vitamin B3)
Omega-3/Fish oil
Potassium
Probiotics
Protein (e.g., powders, drinks, bars)
Selenium
Vitamin A
Vitamin B-complex
Vitamin C
Vitamin D
Vitamin E
Zinc
Other type of vitamin/mineral supplement
BRANDS of Vitamin/Mineral Supplements
Berocca
Caltrate
Centrum
Centrum Silver
Centrum Specialist
Centrum Other
Citrical
Emergen-C
Emergen-Z
Geritol
GNC Ultra Mega
GNC Women's Ultra Mega
Ocuvite
One-A-Day 50+ Advantage
One-A-Day Menopause
One-A-Day Men's Health
One-A-Day Pre-Natal
One-A-Day VitaCraves
One-A-Day Women's
One-A-Day Women's Active Metabolism
One-A-Day Other
Tums
Theragran-M
Viactiv
Vitafusion
Generic/Store brand
Other non-prescription
Acid Reflux/GERD
OTC
Alka-Seltzer
Beano
Gas-X
Gaviscon
Maalox
Mylanta
Nexium 24HR
Pepcid AC
Pepcid Complete
Prevacid
Prilosec OTC
Rolaids
Tagamet HB
Tums
Zantac 150
Zantac 75
Generic/Store brand
Other non-prescription
RX
Aciphex
Cimetidine (Generic for Tagament)
Dexilant
Nexium
Omeprazole (Generic for Prilosec)
Prilosec
Protonix
Ranitidine (Generic for Zantac)
Tagamet
Zantac
Generic prescription
Other prescription
ADD/ADHD
RX
Adderall XR
Concerta
Daytrana
Intuniv
Ritalin
Strattera
Tenex
Vyvanse
Generic prescription
Other prescription
Adult Acne
OTC
Acnefree
Bioré
Clean & Clear
Clearasil
Neutrogena
Oxy
Panoxyl
Proactiv
Generic/Store brand
Other non-prescription
RX
Acanya
Aczone
Benzaclin
Duac/Duac CS
Epiduo Gel
Evoclin
Tazorac
Tetracycline
Generic prescription
Other prescription
Allergies/Allergic Reaction
OTC
Advil Allergy Sinus
Advil Congestion Relief
Alavert
Alka-Seltzer Plus Allergy Tablets
Allegra
Benadryl Allergy
Benadryl Severe Allergy Plus Sinus Headache
Chlor-Trimeton
Claritin
Flonase Allergy Relief
Nasacort Allergy 24HR
Rhinocort
Tylenol Allergy
Zicam Allergy Relief
Zyrtec
Generic/Store brand
Other non-prescription
RX
Adrenaclick (If experienced Anaphylaxis)
Adrenalin (If experienced Anaphylaxis)
EpiPen (If experienced Anaphylaxis)
Grastek
Oralair
Qnasl
Ragwitek
Singulair
Xolair
Generic prescription
Other prescription
Anxiety
RX
BuSpar
Cymbalta
Effexor/Effexor XR
Lexapro
Paxil/Paxil CR
Prozac/Prozac Weekly
Xanax XR
Zoloft
Generic prescription
Other prescription
Arthritis: Ankylosing Spondylitis
OTC
Aleve Arthritis
Tylenol Arthritis Pain
Generic/Store brand
Other non-prescription
RX
Celebrex
Cimzia
Enbrel
Humira
Naprosyn
Percocet/OxyContin (oxycodone)
Remicade
Simponi/Simponi Aria
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Vimovo
Generic prescription
Other prescription
Arthritis: Osteoarthritis
OTC
Aleve Arthritis
Tylenol Arthritis Pain
Generic/Store brand
Other non-prescription
RX
Celebrex
Euflexxa
Hyalgan
Mobic
Naprosyn
Percocet/OxyContin (oxycodone)
Synvisc
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Vimovo
Voltaren
Generic prescription
Other prescription
Arthritis: Psoriatic Arthritis
OTC
Aleve Arthritis
Tylenol Arthritis Pain
Generic/Store brand
Other non-prescription
RX
Cimzia
Enbrel
Humira
Naprosyn
Otezla
Percocet/OxyContin (oxycodone)
Remicade
Simponi/Simponi Aria
Stelara
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Arthritis: Rheumatoid Arthritis
OTC
Aleve Arthritis
Tylenol Arthritis Pain
Generic/Store brand
Other non-prescription
RX
Actemra
Celebrex
Cimzia
Enbrel
Humira
Methotrexate
Mobic
Naprosyn
Orencia
Percocet/OxyContin (oxycodone)
Planquenil
Remicade
Rituxan
Simponi/Simponi Aria
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Vimovo
Xeljanz/Xeljanz XR
Generic prescription
Other prescription
Asthma
OTC
Asthmanefrin
Bronkaid
Primatene Mist
Primatene Tablets
Generic/Store brand
Other non-prescription
RX
Advair
Alvesco
Bevespi Aerosphere
Breo Ellipta
Brovana
Cinqair
Dulera
Flovent
Nucala
ProAir
Proventil HFA
Pulmicort
Serevent
Singulair
Spiriva
Symbicort
Ventolin HFA
Xolair
Generic prescription
Other prescription
Bipolar Disorder
RX
Abilify
Latuda
Risperdal
Saphris
Seroquel XR
Zyprexa
Generic prescription
Other prescription
Blood clots in the legs (DVT)
OTC
Bayer Aspirin 325 mg
Bayer Aspirin Low Dose
Ecotrin
St. Joseph Aspirin
Generic/Store brand
Other non-prescription
RX
Eliquis
Heparin
Lovenox
Naprosyn
Percocet/OxyContin (oxycodone)
Pradaxa
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Warfarin/Coumadin
Xarelto
Generic prescription
Other prescription
Cardiovascular/Heart Disease
OTC
Bayer Aspirin 325 mg
Bayer Aspirin Low Dose
Ecotrin
St. Joseph Aspirin
Generic/Store brand
Other non-prescription
RX
Altace
Atacand
Cardizem
Coreg
Diovan
Effient
Eliquis
Entresto
Lanoxin
Lopressor
Norvasc
Plavix
Pradaxa
Procardia
Ranexa
Tenormin
Toprol-XL
Warfarin/Coumadin
Xarelto
Generic prescription
Other prescription
Cold/Flu/Cough
OTC
Advil Cold & Flu
Advil Cold & Sinus
Afrin Spray
Airborne
Aleve-D Sinus & Cold
Aleve-D Sinus & Headache
Alka-Seltzer Plus Cold
Alka-Seltzer Plus Cold & Cough
Alka-Seltzer Plus Night
Benadryl Allergy Plus Cold
Breathe Right Nasal Strips
Chloraseptic
Cold-Eeze
Contac Cold + Flu
Coricidin HBP
Delsym
Dimetapp
Halls
Luden's
Mucinex
Mucinex DM
Neo-Synephrine
Robitussin
Robitussin Cough Gels
Robitussin Peak Cold
Sudafed
Theraflu
Theraflu Warming Relief
Triaminic
Tylenol Cold
Tylenol Cold & Flu Severe
Tylenol Cold Sore Throat
Vicks Dayquil Cold & Flu
Vicks Formula 44
Vicks NyQuil
Vicks NyQuil Cough
Vicks VapoRub
Zicam Cold Remedy
Generic/Store brand
Other non-prescription
RX
FluMist Quadrivalent (vaccine)
Tamiflu
Generic prescription
Other prescription
Constipation/Irregularity
OTC
Benefiber
Citrucel
Colace
Dulcolax
Ex-Lax
FiberChoice
FiberCon
Metamucil
MiraLAX
Phillips'
Senokot
Generic/Store brand
Other non-prescription
COPD (Including Chronic Bronchitis and Emphysema)
RX
Advair
Anoro Ellipta
Breo Ellipta
Brovana
Combivent Respimat
Daliresp
Dulera
Flovent
ProAir HFA
Proventil
Qvar
Singulair
Spiriva Handihaler
Stiolto
Symbicort
Tudorza Pressair
Ventolin HFA
Generic prescription
Other prescription
Depression
RX
Abilify
Celexa
Cymbalta
Effexor/Effexor XR
Fetzima
Fluoxetine (Generic for Prozac)
Latuda
Lexapro
Paxil/Paxil CR
Pristiq
Prozac/Prozac Weekly
Rexulti
Seroquel XR
Symbyax
Trintellix/Brintellix
Viibryd
Wellbutrin SR/Wellbutrin XL
Zoloft
Generic prescription
Other prescription
Type 1 Diabetes
RX
Glucagon
Humalog
Humulin
Lantus
Levemir
Novolog
Tanzeum
Toujeo
Tresiba
Generic prescription
Other prescription
Type 2 Diabetes
RX
Actos
Amaryl
Bydureon
Byetta
Farxiga
Glucophage/Glucophage XR
Glucotrol/Glucotrol XL
Glyxambi
Humalog
Humulin
Invokana
Janumet
Januvia
Jardiance
Lantus
Levemir
Metformin
Nesina
Novolog
Onglyza
Tanzeum
Toujeo
Tradjenta
Tresiba
Trulicity
Victoza
Welchol
Generic prescription
Other prescription
Diabetic Nerve Pain/Neuropathy
RX
Cymbalta
Lyrica
Metanx
Naprosyn
Percocet/OxyContin (oxycodone)
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Eczema
OTC
Aveeno
Cetaphil
Cortizone-10
Curel
Dove
Eucerin
Jergens
Lubriderm
Neosporin Eczema
Neutrogena
Olay
Vaseline Intensive Care
Generic/Store brand
Other non-prescription
Rx
Desonate
Dovonex
Dupixent
Elidel
Enbrel
Kenalog
Protopic
Topicort
Generic prescription
Other prescription
Enlarged Prostate/Benign Prostate Hyperplasia
RX
Avodart
Cardura
Cialis
Flomax
Proscar
Generic prescription
Other prescription
Erectile Difficulty
RX
Cialis
Levitra
Viagra
Generic prescription
Other prescription
Eye Problems/Eye Disease
OTC
Clear Eyes
GenTeal
Optive
Refresh
Tears Naturale
TheraTears
Visine
Generic/Store brand
Other non-prescription
RX
Restasis
Generic prescription
Other prescription
Fibromyalgia
RX
Cymbalta
Lyrica
Naprosyn
Percocet/OxyContin (oxycodone)
Savella
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Gas
OTC
Alka-Seltzer
Beano
DulcoGas
Gas-X
Maalox
Mylanta
Phazyme
Generic/Store brand
Other non-prescription
Gout
RX
Allopurinol
Colcrys
Naprosyn
Percocet/OxyContin (oxycodone)
Tylenol with Codeine
Uloric
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Heartburn/Indigestion
OTC
Alka-Seltzer
Beano
Gas-X
Gaviscon
Maalox
Mylanta
Nexium 24HR
Pepcid AC
Pepcid Complete
Prevacid
Prilosec OTC
Rolaids
Tagamet HB
Tums
Zantac 150
Zantac 75
Generic/Store brand
Other non-prescription
RX
Aciphex
Cimetidine (Generic for Tagament)
Dexilant
Nexium
Omeprazole (Generic for Prilosec)
Prilosec
Protonix
Ranitidine (Generic for Zantac)
Tagamet
Zantac
Generic prescription
Other prescription
Hepatitis C
RX
Daklinza
Harvoni
Viekira Pak
Sovaldi
Zepatier
Generic prescription
Other prescription
Herpes
RX
Famvir
Valtrex
Zovirax
Generic prescription
Other prescription
High Cholesterol
OTC
Bayer Aspirin 325 mg
Bayer Aspirin Low Dose
Ecotrin
St. Joseph Aspirin
Generic/Store brand
Other non-prescription
RX
Crestor
Lipitor
Lipofen
Liptruzet
Livalo
Lovaza
Niaspan
Praluent
Pravachol
Repatha
Simcor
Tricor
Vascepa
Vytorin
Welchol
Zetia
Zocor
Generic prescription
Other prescription
HIV
RX
Atripla
Complera
Descovy
Genvoya
Isentress
Kaletra
Odefsey
Prezista
Reyataz
Stribild
Tivicay
Triumeq
Truvada
Generic prescription
Other prescription
Hypertension/High Blood Pressure
OTC
Bayer Aspirin 325 mg
Bayer Aspirin Low Dose
Ecotrin
St. Joseph Aspirin
Generic/Store brand
Other non-prescription
RX
Altace
Atacand
Caduet
Cardizem
Cardura
Coreg
Diovan
Lopressor
Lotrel
Norvasc
Procardia
Tenex
Tenormin
Toprol-XL
Generic prescription
Other prescription
Hypothyroidism
RX
Cytomel
Synthroid
Generic prescription
Other prescription
Inflammatory Bowel Disease/IBD
RX
Cimzia
Humira
Naprosyn
Percocet/OxyContin (oxycodone)
Remicade
Simponi/Simponi Aria
Tylenol with Codeine
Tysabri
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Irritable Bowel Syndrome (IBS)
RX
Amitiza
Linzess
Lotronex
Viberzi
Xifaxan
Generic prescription
Other prescription
Low Testosterone
RX
Axiron
Testim
Generic prescription
Other prescription
Lupus (SLE)
RX
Benlysta
Generic prescription
Other prescription
Menopause
RX
Brisdelle
DuaVee
Estrace
Estring
Osphena
Premarin
Prempro
Vagifem
Generic prescription
Other prescription
Menstrual Cramps/PMS
OTC
Midol
Pamprin
ThermaCare Heat Wraps
Generic/Store brand
Other non-prescription
Rx
Paxil/Paxil CR
Zoloft for PMDD
Generic prescription
Other prescription
Migraine Headache
OTC
Advil Migraine
Excedrin Migraine
Motrin Migraine
Generic/Store brand
Other non-prescription
RX
Botox
Imitrex
Maxalt
Naprosyn
Percocet/OxyContin (oxycodone)
Relpax
Sumavel DosePro
Topamax
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Multiple Sclerosis
RX
Ampyra
Avonex
Copaxone
Gilenya
Naprosyn
Percocet/OxyContin (oxycodone)
Rebif
Tecfidera
Tylenol with Codeine
Tysabri
Vicodin/Norco (hydrocodone)
Zinbryta
Generic prescription
Other prescription
Obesity
RX
Belviq
Contrave
Qsymia
Saxenda
Generic prescription
Other prescription
Osteoporosis
RX
Actonel
Boniva
Evista
Fosamax
Prolia
Reclast
Generic prescription
Other prescription
Overactive Bladder
RX
Botox
Detrol LA
Ditropan XL
Myrbetriq
Toviaz
VESIcare
Generic prescription
Other prescription
Psoriasis
RX
Cosentyx
Dovonex
Enbrel
Humira
Methotrexate
Otezla
Remicade
Stelara
Talz
Tazorac
Generic prescription
Other prescription
Restless Leg Syndrome (RLS)
RX
Mirapex
Naprosyn
Percocet/OxyContin (oxycodone)
Requip
Tylenol with Codeine
Vicodin/Norco (hydrocodone)
Generic prescription
Other prescription
Rosacea
OTC
Aveeno
Cetaphil
Eucerin
Nivea
Olay
Generic/Store brand
Other non-prescription
RX
Finacea
MetroGel
Mirvaso
Oracea
Soolantra
Generic prescription
Other prescription
Seizure/Epilepsy
RX
Depakote/Depakote ER
Dilantin
Keppra/Keppra XR
Lamictal
Lyrica
Neurontin
Topamax
Generic prescription
Other prescription
Shingles
RX
Dilantin
Famvir
Naprosyn
Neurontin
Percocet/OxyContin (oxycodone)
Tylenol with Codeine
Valtrex
Vicodin/Norco (hydrocodone)
Zostavax (vaccine)
Zovirax
Generic prescription
Other prescription
Sleeping Difficulty/Insomnia
OTC
Excedrin PM
MidNite
Nytol QuickCaps
Simply Sleep
Sleepinal
Sominex
Unisom
Zzzquil
Generic/Store brand
Other non-prescription
RX
Ambien CR
Belsomra
Intermezzo
Lunesta
Generic prescription
Other prescription
Smoking Cessation
OTC
Electronic Cigarettes (e.g. bluCigs) or Vaporizers
NicoDerm CQ
Nicorette Gum
Nicorette Lozenge
Generic/Store brand
Other non-prescription
RX
Chantix
Nicotrol Inhaler
Wellbutrin/Wellbutrin XL
Generic prescription
Other prescription
Women's Health/Birth Control
Birth Control Methods
Have you used any of the following methods of birth control in the last 12 months?
Abstinence
Barrier methods (e.g., condoms, diaphragm, cervical cap, sponge, spermicide)
Fertility awareness (e.g., calendar/ovulation tracking, temperature method)
Long-term methods (e.g., implant, IUD, patch, ring, shot)
Oral contraceptives/birth control pills
Permanent procedures (e.g., tubal ligation, partner vasectomy)
Withdrawal method
Other method
Have not used birth control in last 12 months
Decline
OTC Treatments
Plan B One-Step
Generic/Store brand
Other non-prescription
Rx Treatments
IUD (intrauterine devices)
Liletta IUD
Mirena IUD
ParaGard IUD
Skyla IUD
Oral Contraceptives/Pills
Beyaz
Lo Loestrin Fe
Minastrin 24 Fe
Ortho Tri-cyclen
Ortho Tri-cyclen Lo
Ocella
Seasonique
Yasmin
Yaz
Shots/Implants/Rings/Patches
Depo-Provera (shot)
Essure (shot)
Nexplanon (implant)
NuvaRing (ring)
Xulane (patch)
Other Rx
Generic prescription
Other prescription
Yeast Infection
OTC
Gyne-Lotrimin
Monistat 1 Day or Night
Monistat 1 or 3 or 7
Vagisil
Generic/Store brand
Other non-prescription