Measures of Patient Adherence Measures of Patient Adherence Your Name Date of Birth Gender ---FemaleMale Surgery Doctor Date PLEASE ANSWER THE FOLLOWING QUESTIONS OF THIS HEALTH SURVEY COMPLETELY, HONESTLY AND WITHOUT INTERRUPTIONS. MEDICAL OUTCOMES STUDY GENERAL ADHERENCE ITEMS How often was each of the following statements true for you during the past 4 weeks? 1. I had a hard time doing what the doctor suggested I do ---6 None of the time5 A little bit of the time4 Some of the time3 A good bit of the time2 Most of the time1 All of the time 2. I followed my doctor’s suggestions exactly ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 3. I was unable to do what was necessary to follow my doctor’s treatment plans ---6 None of the time5 A little bit of the time4 Some of the time3 A good bit of the time2 Most of the time1 All of the time 4. I found it easy to do the things my doctor suggested I do ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 5. Generally speaking, how often during the past 4 weeks were you able to do what the doctor told you? ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time MEDICAL OUTCOMES STUDY SPECIFIC ADHERENCE RECOMMENDATIONS This is a list of things your doctor, a nurse, or other health care professional may have recommended that you do as part of your treatment. Please indicate if your doctor, a nurse or other health care professional has recommended that you do this now. 1. Follow a low salt diet? ---2 Yes1 No 2. Follow a low salt or weight loss diet? ---2 Yes1 No 3. Follow a diabetic diet? ---2 Yes1 No 4. Take a prescribed medication? ---2 Yes1 No 5. Check your blood for sugar? ---2 Yes1 No 6. Take part in a cardiac rehabilitation program? ---2 Yes1 No 7. Exercise regularly? ---2 Yes1 No 8. Socialize more than usual with others? ---2 Yes1 No 9. Cut down on the alcohol you drink? ---2 Yes1 No 10. Stop or cut down on smoking? ---2 Yes1 No 11. Check your feet for minor bruises, injuries, and ingrown toenails? ---2 Yes1 No 12. Cut down on stress in your life? ---2 Yes1 No 13. Use relaxation techniques like biofeedback or self-hypnosis? ---2 Yes1 No 14. Carry something with sugar in it as a source of glucose for emergencies? ---2 Yes1 No 15. Carry medical supplies needed for your self-care? ---2 Yes1 No MEDICAL OUTCOMES STUDY SPECIFIC ADHERENCE BEHAVIOURS How often have you done each of the following in the past 4 weeks? 1. Followed a low salt diet ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 2. Followed a low fat or weight loss diet ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 3. Followed a diabetic diet ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 4. Took prescribed medication ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 5. Checked your blood for sugar ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 6. Took part in a cardiac rehabilitation program ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 7. Exercised regularly ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 8. Tried to socialize more with others ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 9. Cut down on the alcohol you drank ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 10. Stopped or cut down on smoking ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 11. Checked your feet for minor bruises, injuries, and ingrown toenails ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 12. Cut down on stress in your life ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 13. Used relaxation techniques (biofeedback, self-hypnosis, yoga, etc.) ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 14. Carried something with sugar in it (a source of glucose) for emergencies when outside your home ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time 15. Carried medical supplied needed for your self-care when outside your home ---1 None of the time2 A little bit of the time3 Some of the time4 A good bit of the time5 Most of the time6 All of the time THANK YOU FOR COMPLETING THIS QUESTIONNAIRE STAFF USE ONLY Participants NHS Number: Researchers Name: NHS Site Number:
