SCI English

Authored by
Barbara Riegel, PhD, RN, FAAN, FAHA
Professor of Gerontology
Penn Nursing
University of Pennsylvania
418 Curie Boulevard
Philadelphia, PA 19104-4217
email: briegel@nursing.upenn.edu
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 |
14. Think about the last time you had a symptom. This can be a symptom of anything – a cold, a bad night sleep, an illness. It could also be a reaction to a medicine.
(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 |
Think of things you did the last time you had a symptom…
(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!