1.

Name -
_____________________________________________________
(First Name) (Last name’s first alphabet)

2. Age - _____________

3. Gender -
 Male
 Female

4. Qualification - ____________________________________________

5. Profession - ______________________ Location (city) - __________

6. Stress at work
 None
 Less
 Moderate
 High

7. Work Type –
 Office Work
 Field Work
 Both

8. Are you aware of reduction in Drug Price ?

 Yes
 No

9. Are you on any kind of medication ?

 Yes
 No
10. For disease you take medicine for
 Diabetes
 Respiratory Infection
 Bones Weakness ( Join, Knee problems)
 Heart disease
 Cancer
 Constipation (Stomach related)
 Other

11. How frequently you use Drugs for it ?

 Daily
 Weekly
 Monthly

12. How frequently you visit, the Hospital Doctors ?

 Weekly
 Monthly
 Once in 3 months
 Once in 6 months
 Once a year

13. Do you buy your Medication ? By Doctor or by Pharmacists ?

Doctor Prescribed :-

Strongly 0 1 2 3 4 5 Strongly
Disagree Agree

Pharmacists Prescribed :-

Strongly 0 1 2 3 4 5 Strongly
Disagree Agree
14. How much do the medication cost monthly ?
 Rs. 0 - 500
 Rs. 500 - 1000
 Rs. 1000 - 2000
 Rs. 2000 - 3000
 Rs. 3000 & above

15. What is the availability of those drugs ?

 Easily available
 Moderately available
 Hard to find

16. Do you take Generic Medicine or Branded Medicine ?

 Generic
 Branded

17. Is Generic Medicine cost saving or effective ?

 Cost Saving
 Effective
 Both

18. Does the price reduction will affect your medication budget ?
 Yes
 No

19. How much do you will save after price reduction ?

 Rs. 0 - 100
 Rs. 100 - 300
 Rs. 300 - 800
 Rs. 800 & more
20. Since how many days you are using this drugs for your medication ?
 7 to 8 days
 2 weeks - 4 weeks
 1 month - 6 months
 6 months - 1 year
 More than 1 year

21. Anyone from your family is on medication ?

 Spouse
 Parents
 Siblings
 Children

22. Do you smoke or consume alcohol ?

Low Medium High
a) Smoke   
b) Alcohol   
c) Tobacco   

23. Do you do any kind of exercise ?

 Running
 Yoga
 Gym
 Other