3M survey5

3M survey

DCS-C Quality of Life Questionnaire

ABOUT THIS QUESTIONNAIRE

These questions ask about you, your disability or condition, and its treatment.

Please think carefully about each question. They can be answered simply by checking the line or circling the number next to the answer which best applies to you.

If you are unsure how to answer any questions, please give the best answer you can and write in any comments you want to make.

Part 1. Please provide the following information about yourself:

1. How old are you (in years)? Years

2. Are you female or male?

2a. What is your disability or chronic illness?

3. Which item best describes your race (ethnic group)?

	African American		Native American
	Asian or Pacific Islander		White (non-Hispanic)
	Hispanic		Other:

4. What is your marital status ?

	married or living as married		divorced
	Separated		never married
	Widowed		other

5. Which of the following best describes your highest level of education ?

	Less than high school		College graduate
	High school grad. or equivalent		Master’s degree or higher
	Some college or technical school

6. Which of the following best describes your position about paid work?

	Employed full-time		Employed Part-Time
	Unemployed- Seeking work		Homemaker
	Student		Permanent Disability
	Retired		Number of hours per week:

7. What is your approximate monthly household income ?

	Less than $500		$2,000- 2,999
	$500 - 999		$3,000 – 3,999
	$1,000 - 1,999		over $4000

Part 2. Information About Your Disability or Condition

1. If you have a disability or condition that affects your ability to function as you would like to, please label it here:

How old were you when you were diagnosed or started experiencing this condition?

years

3. At the present time how disabled are you by your condition?

Fully Dependent on

Independent others for all care

4. Do you have any other medical conditions or illnesses?

Yes No

If ‘Yes’ please describe:

___________________________________________________________

Part 3. Your Quality of Life:

Check the box which best describes how you feel about YOUR LIFE AS A WHOLE

Very Very

Bad Good

Part 4. Ladder of Adjustment

Suppose that a person's overall adjustment to a disability could be shown on a ladder having 10 steps with the tenth step representing the best possible adjustment and the first representing the worst possible. On what step of the ladder would you place yourself to indicate your current overall adjustment (1-10) (check one)?

10 – Best Possible Adjustment

_____ 9

_____ 8

_____ 7

_____ 6

_____ 5

_____ 4

_____ 3

_____ 2

_____ 1 – Worst Possible Adjustment

Where on the ladder do you expect yourself to be in five years (1-10) (check one)?

10-Best Possible Adjustment

_____ 9

_____ 8

_____ 7

_____ 6

_____ 5

_____ 4

_____ 3

_____ 2

_____ 1 – Worst Possible Adjustment

Part 5. Disability Centrality Scale

Finally, we would like to think about a number of different areas of your life, including things like your physical health, emotional health, your relationships with family and friends, your work, and so on. For each of the 10 parts of your life on the next few pages, please answer the following questions by clicking on the circle of the number that is right for you. The questions ask about:

1. Importance: How important is this part of your life in contributing to your overall quality of life?

2. Satisfaction: How satisfied are you with how this part of your life is going?

3. Control: How much control do you have over this part of your life? In other words: How much do you feel like you

could change things in this part of your life if you wanted to?

4. Interference: How much does your illness or disability and/or its treatment

interfere with your ability to function in this area of your life as you would like to?

Part 6. Stigma

Please answer the following questions concerning your current disability.

If neighbors, colleagues and others knew someone with health problems like mine they would think less of the family of that person
True False
One problem with having health problems like mine is that people don’t believe that you really have the symptoms that you say you do.
True False
If others knew, that a person had health problems like mine, it would be more difficult for that person to get married
True False
Most people who have health problems like mine think less of themselves
True False
Most people believe that a person with health problems like mine is just as emotionally stable as the average person.
True False
I rarely feel the need to hide the fact that I have seen a doctor for my health problems
True False
Health problems like mine might cause people to have difficulties in their marriages
True False
I have sometimes wished that people could see my symptoms
True False
Most people would willingly accept a person with health problems like mine as a close friend.
True False
People have a way of making a person with health problems like mine feel ashamed or embarrassed.
True False
Having health problems has made me feel very different from other people.
True False
Many people assume that a person who suffers from health problems like mine has a deep seated psychological problem as well.
True False
When people learn that you have been treated for health problems like mine, they begin to search for flaws in your personality.
True False
Most employers will pass over the application of a person with health problems like mine in favor of another applicant.
True False
There is a part of me that only other people who have experienced health problems like mine can understand.
True False
People have a way of associating the occurrence of health problems like mine with psychiatric difficulties.
True False
I often feel totally alone with my symptoms.
True False
Most people have no idea what it is like to have health problems like mine.
True False
Many people assume that having health problems like mine is a sign of personal weakness.
True False
People often try to avoid a person with health problems like mine.
True False
Most employers will hire a person with health problems like mine if he or she is qualified for the job.
True False

Part 8 Self Advocacy

Please indicate your level of agreement with the following statements:

Family coping

Part 9. Adherence Scale

This section deals with medications you take for your primary medical condition (e.g. chronic illness or disability)

What medications has your doctor prescribed for your condition

Name of medication	Number of pills prescribed (per day)	Number of pills taken yesterday	Number of pills taken two days ago	Number taken three days ago
Times taken per day:
Times taken per day
Time taken per day

How much money do you spend monthly on your medication? $
How much money do you spend monthly on other health care costs associated with your condition?$
How much time on average do you wait to see your doctor when you have an appointmentminutes
What is the distance in miles to your doctor appointments?miles
What is the distance to pick up your medication(s)?miles
How many days have you missed work due to your condition in the past month?days
How many days have you stayed overnight at a hospital in the last 12 months due to your condition?days
How often do you use illegal drugs (e.g. marijuana, cocaine) in an average month?days
How many alcoholic drinks did you have yesterday?drinks
How many alcoholic drinks have you had in the past 7 days?drinks
How many doctors appointments have you had in the past 30days?
How many doctors’ appointments did you miss in the last 30 days?
How long do your doctor appointments last on average?minutes

When you did not take your medication in the last three days it was because:

__I don’t like the taste

__I don’t like the effects they have on my body

__I simply forgot

__I did not want to take it in front of others

__There was a change in my schedule

__The medication makes me feel worse

__It makes me gain weight

__I don’t like the effect the medication has on my appearance

__I was asleep when I was suppose to take it

__I ran out

__I only take the medication when I don’t feel well

__I resent having to take the medication

__I don’t think the medication helps

__My body sometimes needs a rest from the medication

__I was too busy to take the medication

__ Other:_

Have you experienced any of the following as a result of your medication in your opinion (check as many as apply):

__Diarrhea

__Drowsiness

__Sexual problems

__Anxiety

__Not wanting to eat

__Weight gain

__A need for more sleep

__Other health problems

__Not being able to participate in other activities you enjoy

__Other:

Do you take your medications with a meal?

Yes No

Are there other things your medical doctor has asked you to due to your condition in regards to:

Exercise:

Diet:

Avoiding alcohol:

Daily activity changes such as going to bed at a certain time etc:

Do you take any medication that was not prescribed to you by your Doctor

Never sometimes often always

What medication:

Why do you take this medication?

In general how would you rate your primary doctor’s treatment of your condition:

Excellent Good Average Not good Very Poor

In general how much do you trust your primary doctor:

Very much Moderately Minimally Not at all

We thank you for participation in this research. If you would be willing to participate in future research so that we can see how things change for you over time, we will send an invitation form to you via e-mail if you’ll provide your address. No other information will be sent to this e-mail address.

My e-mail address:

my user name (please use a name you will remember)

If you have any comments or questions about this survey, feel free to contact the us at through e-mail or phone or write them in here.

By clicking on the button below you are submitting your survey.

Hit Counter

		Strongly agree	Agree	Neutral	Disagree	Strongly disagree
1.	I believe it is important for people with a disability (e.g. MS) to learn as much as they can about their illness and treatments.
2.	I don’t get what I need from my physician because I am not assertive enough.
3.	I don’t always do what my physician or health care worker has asked me to do.
4.	I have full knowledge of the health problems of people like myself (people with MS or other disability).
5.	I am more assertive about my health care needs than most U.S. citizens.
6.	Sometimes there are good reasons not to follow the advice of a physician.
7.	I actively seek out information about my disability (chronic illness such as MS).
8.	I frequently make suggestions to my physician about my health care needs.
9.	Sometimes I think I have a better grasp of what I need medically than my doctor does.
10.	I am more educated about my health than most US citizens.
11.	If my physician prescribes something I don’t understand or agree with I question it.
12.	If I am given a treatment by my physician that I don’t agree with, I am likely to not take it.

Self-efficacy	Think about how you have been feeling over the last week. Please read the following statements and indicate the extent to which you agree or disagree with them clicking on the circle of one answer to each question.	Strongly agree	Agree	Disagree	Strongly Disagree
1.	Since my diagnosis was confirmed, my life has been beset with difficulties over which I have no control.
2.	I feel in control of my life.
3.	I rely on others to help me make decisions.
4.	Sometimes I feel that my disability or illness controls my life.
5.	I often feel helpless when dealing with my difficulties.
6.	The way my illness affects me in the future mostly depends on me.
7.	I worry about how I will cope in the future.
8.	Despite my difficulties, I still mange to cope with daily life.
9.	There is really no way I can solve some of the problems I have with my illness.
10.	Despite my illness, I can do anything I set my mind to.
11.	I am confident I can overcome my difficulties.

When we face problems or difficulties in our family, we respond by:		Strongly Disagree	Moderately Disagree	Neither Agree Nor Disagree	Moderately Agree	Strongly Agree
1.	Sharing our difficulties with relatives
2.	Seeking encouragement and support from friends
3.	Knowing we have the power to solve major problems
4.	Seeking information and advice from persons in other families who have faced the same or similar problems
5.	Seeking advice from relatives
6.	Seeking assistance from community agencies and programs designed to help families in our situation
7.	Knowing that we have the strength within our own family to solve our problems
8.	Receiving gifts and favors from neighbors (e.g. food, taking in mail, etc.)
9.	Seeking information and advice from the family doctor
10.	Asking neighbors for favors and assistance
11.	Facing the problems "head-on" and trying to get solutions right away
12.	Watching television
13.	Showing that we are strong
14.	Attending church services
15.	Accepting stressful events as a fact of life
		Strongly Disagree	Moderately Disagree	Neither Agree Nor Disagree	Moderately Agree	Strongly Agree
16.	Sharing concerns with close friends
17.	Knowing luck plays a big part in how well we are able to solve family problems
18.	Exercising with friends to stay fit and reduce tension
19.	Accepting that difficulties occur unexpectedly
20.	Doing things with relatives (get-togethers, dinners, etc.)
21.	Seeking professional counseling and help for family difficulties
22.	Believing we can handle our own problems
23.	Participating in church activities
24.	Defining the family problem in a more positive way so that we do not become too discouraged
25.	Asking relatives how they feel about problems we face
26.	Feeling that no matter what we do to prepare, we will have difficulty handling problems
27.	Seeking advice from a minister
28.	Believing if we wait long enough, the problem will go away
29.	Sharing problems with neighbors
30.	Having faith in God.

When considering your primary medical condition please answer the follow		Strongly Disagree	Moderately Disagree	Neither Agree Nor Disagree	Moderately Agree	Strongly Agree
1.	Purchasing my medication puts significant strain on my financial situation.
2.	I have insurance that pays for my medication
3.	Getting transportation to my doctor’s appointments is a problem for me.
4.	There are aspects of my life that make it difficult to make it to my doctors appointments (e.g. need for a babysitter)
5.	On most days I like the person I am.
6.	Most decisions in my life I make on my own (or with my partner)
7.	There are few outside (e.g. financial) limits to the decisions I make in life.
8.	My immediate family is very supportive of me in handling my condition.
9.	A family member administers and/or controls my medication.
10.	I have been asked to make changes to my diet due to my condition.
11.	I closely follow the diet recommendations I have been given.
12.	Taking my medication leads to the things I value in my life being met.
13.	I need assistance in keeping track of taking my medication?
14.	I have peers who support my taking of my medication
15.	My co-workers and supervisors at work support me taking my medication.
		Strongly Disagree	Moderately Disagree	Neither Agree Nor Disagree	Moderately Agree	Strongly Agree
16.	I have never had a mental illness diagnosis.
17.	I am confident in my ability to properly take my medication.
18.	I am confident I need to take my medication to be healthy.
19.	I understand why I take my medication.
20.	I am knowledgeable about my medication (e.g. how well it works, expected side effects)
21.	The schedule of when and how I take my medications is difficult to understand.
22.	After I take my medication my body feels positive effects almost right away.
23.	The medication I take has unpleasant side effects
24.	I have confidence in the treatment approach of my medical provider.
25.	I have confidence that my medical professional keeps my information confidential.
26.	My medical provider is very willing to answer all of my questions concerning my condition.
27.	My doctor and I have very good communication about my condition.
28.	My doctor and I agree on what my illness is.
29.	My doctor and I agree on how serious my illness is.
30.	My doctor has empathy for my condition.

Part 2. Information About Your Disability or Condition

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

IMPORTANCE

SATISFACTION

CONTROL

INTERFERENCE

When we face problems or difficulties in our family, we respond by:

When considering your primary medical condition please answer the follow

When we face problems or
difficulties in our family, we respond by: