TABLE 1.

Suggested Checklist for Identifying Patients at High Risk for Medication Nonadherence

Evidence-Identified FactorsMeasures
Socio-demographic factorsEthnicity❏ Hispanic ❏ Non-Hispanic
Race❏ White ❏ African American ❏ Asian ❏Multiracial
❏ Other (Specify:________________________________ )
Age❏ Young (<39 years) ❏ Middle-aged (40–64 years)
❏ Old (65–74 years) ❏ Elderly (≥75 years)
Education❏ < High school ❏ High school graduate ❏ ≥High school
Low incomeBelow 200% of federal poverty level? ❏ No ❏ Yes
AcculturationLanguage barrier? ❏ No ❏ Yes
Immigration? ❏ No ❏ Yes (When?__________________ )
Acculturation (e.g., follows U.S. practices)? ❏ No ❏ Yes
Health insuranceHas health insurance? ❏ No ❏ Yes
Has prescribed drug coverage? ❏ No ❏ Yes
Living conditionsWorking ≥2 jobs: ❏ No ❏ Yes
❏ Married (or living with someone)
❏ Unmarried (or living alone)
Patient factorsUnderstanding of diabetes❏ No ❏ Yes
Experiencing diabetes symptoms❏ No ❏ Yes (Specify:________________________________ )
Comorbidities1. 2. 3.
Poor eyesight/hearingGlasses? ❏ No ❏ Yes; Vision corrected? ❏ No ❏ Yes
Hearing aids? ❏ No ❏ Yes; Hearing corrected: ❏ No ❏ Yes
Cognitive functionHow frequently does patient experience forgetfulness?
❏ Never ❏ Hardly ever ❏ Sometimes ❏ Often ❏ Always
Emotional states (all that apply)❏ Depression ❏ Anxiety ❏ Denial ❏ Fear
❏ Other (Specify:________________________________ )
Coping skills❏ Inadequate ❏ Adequate
Trust in HCP❏ No ❏ Yes
Social support (all that apply)❏ Spouse/partner ❏ Family ❏ Friend(s)
In need of ancillary resources (e.g., dental care, pharmacy, or nutrition counseling)Expressing need of ancillary resources?
❏ No ❏ Yes (Specify:________________________________ )
Awareness/usage of ancillary resources❏ Nutrition counseling
❏ Peer support
❏ Community outreach program (Specify:___________________ )
❏ Other (Specify:___________________ )