SC-CHDI (English) V2.2

Authored by
Victoria V. Dickson, PhD, RN, FAHA, FAAN
Director, Pless Center for Research
NYU Rory Meyers College of Nursing
433 First Avenue
New York, NY 10010
p +1 212 998 5300
e vdickson@nyu.edu
Barbara Riegel, PhD, RN, FAHA, FAAN
Professor and Edith Clemmer Steinbright Chair of Gerontology
University of Pennsylvania, School of Nursing
Claire M. Fagin Hall, 418 Curie Boulevard
Philadelphia, PA 19104-4217
briegel@nursing.upenn.edu
215-898-9927 Phone
240-282-7707 eFax
SELF-
(SC-CHDI V2.1)
All answers are confidential.
Think about how you have been feeling in the last month or since we last spoke as you complete these items.
SECTION A:
Listed below are common instructions given to persons with heart disease. How routinely do you do the following?
Never or rarely |
|
Sometimes |
|
Always or daily |
|
1.
Keep doctor or nurse appointments? |
1 |
2 |
3 |
4 |
5 |
2.
Take aspirin or other blood thinner? |
1 |
2 |
3 |
4 |
5 |
3.
Check your blood pressure? |
1 |
2 |
3 |
4 |
5 |
4.
Exercise for 30 minutes? |
1 |
2 |
3 |
4 |
5 |
5.
Take your medicines as prescribed? |
1 |
2 |
3 |
4 |
5 |
6.
Ask for low fat items when eating out or
visiting others? |
1 |
2 |
3 |
4 |
5 |
7.
Use a system to help you remember your medicines? For example, use a
pill box or reminders. |
1 |
2 |
3 |
4 |
5 |
8.
Eat fruits and vegetables? |
1 |
2 |
3 |
4 |
5 |
9.
Avoid cigarettes and/or smokers? |
1 |
2 |
3 |
4 |
5 |
10. Try to lose weight or control your body weight? |
1 |
2 |
3 |
4 |
5 |
SECTION B:
Heart disease may
appear as chest pain, chest pressure,
burning, heaviness, shortness of breath, or fatigue. The last time you had
these symptoms …
|
Have not had symptoms |
I did not recognize the symptoms |
Not Quickly |
|
Somewhat Quickly |
|
Very Quickly |
1. … how quickly did you recognize
them as symptoms of heart disease? |
N/A |
0 |
1 |
2 |
3 |
4 |
5 |
Listed below are actions that people with heart disease use. If you have symptoms, how likely are you to try one of these actions?
Not Likely |
|
Somewhat Likely |
|
Very Likely |
|
2. Change your activity level (slow down, rest) |
1 |
2 |
3 |
4 |
5 |
3.
Take nitroglycerin (If you do
not have nitroglycerin prescribed, skip this item) |
1 |
2 |
3 |
4 |
5 |
4. Call your doctor or nurse
for guidance |
1 |
2 |
3 |
4 |
5 |
5.
Take an aspirin |
1 |
2 |
3 |
4 |
5 |
Think of an action you tried the last time
you had symptoms of heart disease
(circle one number)
|
I did not do anything |
Not Sure |
|
Somewhat Sure |
|
Very Sure |
6. How sure were you that the action helped or
did not help? |
0 |
1 |
2 |
3 |
4 |
5 |
© Copyright held by Dr. Barbara Riegel