Patient code
Assessment data
Administrator:
SERAD 1.1
LAST WEEK
A
HOUR
B
C
MEDICATION
Nº
PILLS
D
E
Nº of times
that a dose
was not
taken
LAST MONTH
F
G
H
I
J
Σ
Reasons for
no
consumption
(eg: a3; b1)
Nº of times
that intake
conditions
were not
respected
Reasons for
no respect
(eg: a3; f1)
Nº of times
that a dose
was not
taken
total pills not
taken per
dose
K
L
M
N
Σ
Reasons for no
consumption
(eg: 3a; 1f)
Nº of times that
intake
conditions were
not respected
Reasons for no
respect
(eg: a3; f1
total pills not
taken per
dose
a)
b)
c)
d)
e)
h)
Be on other things incompatible with
medication’s intake
Avoid other people being aware
medication’s intake
Changes in daily routine (holidays,
week-end…)
Being ill
i)
j)
k)
l)
Too many pills to take
Feel depressed or unmotivated
Run out of medication
Not willing to take medication
m)
Clinician’s prescription
Misunderstanding clinician’s prescription
Others
f)
g)
BREAKFAST
DINNER
n)
o)
Apart from this last month,
how many times do you
remember not having taken
your medication?
SUPPER
Time:
TOTAL
C
TOTAL
E
TOTAL
D
minutes
Not having the medication at
dose’s time
Simply forget
Try to avoid adverse events
Be asleep
TOTAL
F
AG
BG
CG
DG
EG
FG
GG
HG
IG
JG
KG
LG
MG
NG
OG
TOTAL H
AI
BI
CI
DI
EI
FI
GI
HI
II
JI
KI
LI
MI
NI
OI
TOTAL J
TOTAL K
AL
BL
CL
DL
EL
FL
GL
HL
IL
JL
KL
LL
ML
NL
OL
TOTAL M
AN
BN
CN
DN
EN
FN
GN
HN
IN
JN
KN
LN
MN
NN
ON
None
1 or 2 times
3 to 5 times
6 to 10 times
11 or more times
Reasons for not
consumption: