Patient Version SCI – English | Self Care Measures

SCI English

Professor of Gerontology

Penn Nursing
University of Pennsylvania
418 Curie Boulevard
Philadelphia, PA 19104-4217

SELF-CARE INVENTORY

All answers are confidential.

Think about how you have been feeling in the last month as you complete this survey.

SECTION A:

Listed below are common self-care behaviors that people may do. How often or routinely do you do the following?

	Never		Sometimes		Always
1. Make sure to get enough sleep?	1	2	3	4	5
2. Try to avoid getting sick (e.g., flu shot, wash your hands)?	1	2	3	4	5
3. Do physical activity (e.g., take a brisk walk, use the stairs)?	1	2	3	4	5
4. Eat a balanced and varied diet?	1	2	3	4	5
5. See your healthcare provider for routine health care (e.g. routine check ups, dentist, gynecologist)?	1	2	3	4	5
6. If/when prescribed, take prescribed medicines without missing a dose?	1	2	3	4	5
7. Do something to relieve stress (e.g., meditation, yoga, music)?	1	2	3	4	5
8. Do you avoid tobacco smoke?	1	2	3	4	5

SECTION B:

Listed below are common things that people monitor. How often or routinely do you do the following?

	Never		Sometimes		Always
9. Monitor your health status?	1	2	3	4	5
10. If/when prescribed, monitor for medicine side-effects?	1	2	3	4	5
11. Pay attention to changes in how you feel?	1	2	3	4	5
12. Monitor whether you tire more than usual doing normal activities?	1	2	3	4	5
13. Monitor for symptoms?	1	2	3	4	5

(circle one number)

	I did not recognize the symptom	Not Quickly		Somewhat Quickly		Very Quickly
How quickly did you recognize it as a symptom of an illness, health problem or medicine side effect?	0	1	2	3	4	5

SECTION C:

Listed below are behaviors that people use to control their symptoms. When you have symptoms, how likely are you to use one of these?

(circle one number for each behavior)

	Not Likely		Somewhat Likely		Very Likely
15. Change what you eat or drink to make the symptom decrease or go away?	1	2	3	4	5
16. Change your activity level (e.g. slow down, rest)?	1	2	3	4	5
17. Take a medicine to make the symptom decrease or go away?	1	2	3	4	5
18. Tell your healthcare provider about the symptom at the next office visit?	1	2	3	4	5
19. Call your healthcare provider for guidance?	1	2	3	4	5

(circle one number)

	I did not do anything	Not Sure		Somewhat Sure		Very Sure
20. Did the things you did make you feel better?	0	1	2	3	4	5

SECTION D: SELF-CARE SELF-EFFICACY SCALE

In general, how confident are you that you can:

(Circle one number for each statement)

	Not Confident		Somewhat Confident		Very Confident
21. Keep yourself stable and free of symptoms?	1	2	3	4	5
22. Follow the plan if you have been given a treatment?	1	2	3	4	5
23. Persist in following the plan if you have been given a treatment even when difficult?	1	2	3	4	5
24. Monitor your health status routinely?	1	2	3	4	5
25. Persist in routinely monitoring your health status even when difficult?	1	2	3	4	5
26. Recognize changes in your health if they occur?	1	2	3	4	5
27. Evaluate the importance of your symptoms?	1	2	3	4	5
28. Do something to relieve your symptoms?	1	2	3	4	5
29. Persist in finding a remedy for your symptoms even when difficult?	1	2	3	4	5
30. Evaluate how well a remedy works?	1	2	3	4	5

THANK YOU FOR COMPLETING THIS SURVEY!