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4. If you were given a prescription for opioids, how many opioid pills were you
prescribed?
_________________________________________________________________
_________________________________________________________________
5. Did you fill the prescription?
☐ Yes
☐ No
6. Did you need more pills?
☐ Yes
☐ No
7. How long did you need opioids for pain control (e.g. 5 days, 7 days, 14 days, 1 month)?
_________________________________________________________________
8. Were you instructed to use the lowest dose of opioids for the shortest amount of time?
☐ Yes
☐ No
9. Did you experience any of the following opioid side effect symptoms?
(please check all that apply):
☐ Nausea
☐ Vomiting
☐ Constipation
☐ Drowsiness
☐ Itching
☐ Dizziness
☐ Depression
10. Where did you store your opioids, and was this location locked and secure?
_________________________________________________________________
_________________________________________________________________
11. How many pills did you have leftover?
_________________________________________________________________
12. How did you dispose of the leftover opioids?
_________________________________________________________________
_________________________________________________________________
Adapted from the American College of Surgeons patient education brochure on Safe and Effective Pain
Control Aer Surgery.
