Patient Version Self-Care of Chronic Illness Inventory V4c (English)

Authored By

Tiny Jaarsma

Email: tiny.jaarsma@liu.se

Anna Stromberg

Email: anna.stromberg@liu.se

Barbara Riegel

Email: briegel@nursing.upenn.edu

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We are interested in the support you give and get from relationships

SELF-CARE OF CHRONIC ILLNESS INVENTORY v.4c

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-help behaviors that people with a chronic illness may do. How often or routinely do you do the following?

	Never	Rarely		Sometimes		Often			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 special foods or avoid certain foods?	1		2		3		4	5
5. Keep appointments for routine or regular health care?	1		2		3		4	5
6. Take prescribed medicines without missing a dose?	1		2		3		4	5
7. Do something to relieve stress (e.g., mindfulness, yoga, music)?	1		2		3		4	5

SECTION B:

Listed below are common things that people with chronic illness monitor. How often do you do the following?

	Never	Rarely	Sometimes	Often	Always
8. Monitor your health condition?	1	2	3	4	5
9. Monitor for medication side-effects?	1	2	3	4	5
10. Pay attention to changes in how you feel?	1	2	3	4	5
11. Monitor whether you tire more than usual doing normal activities?	1	2	3	4	5
12. Monitor for symptoms?	1	2	3	4	5

13. Many patients have symptoms due to their health condition or due to the treatment they receive for it. The last time you had a symptom, how quickly did you recognize it as a symptom of your health condition?

ÿ I never had a symptom. If you check this box, skip to Section C below.

ÿ I had a symptom but did not recognize it as a symptom of my health condition

ÿ I had a symptom and recognized it as a symptom of my health condition (Circle one)

o Not Quickly

o Fairly Quickly

o Somewhat Quickly

o Moderately Quickly

o Very Quickly

SECTION C:

Listed below are behaviors that people with chronic illness 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	Moderately Likely	Likely	Very Likely
14. Change what you eat or drink to make the symptom decrease or go away?	1	2	3	4	5
15. Change your activity level (e.g., slow down, rest)?	1	2	3	4	5
16. Take a medicine to make the symptom decrease or go away?	1	2	3	4	5
17. Tell your healthcare provider about the symptom at the next office visit?	1	2	3	4	5
18. Call your healthcare provider for guidance?	1	2	3	4	5

(circle one number)

	I did not do anything	Not Sure	Somewhat sure	Moderately Sure	Sure	Very Sure
19. Think of a treatment you used the last time you had symptoms. Did the treatment you used make you feel better?	0	1	2	3	4	5

SECTION D: SELF-CARE CONFIDENCE SCALE

In general, how confident are you that you can:

(Circle one number for each statement)

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

THANK YOU FOR COMPLETING THIS SURVEY!