Form A
Instructions: Each item below is a belief statement about your medical condition with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree (1) to strongly agree (6). For each item we would like you to circle the number that represents the extent to which you agree or disagree with that statement. The more you agree with a statement, the higher will be the number you circle. The more you disagree with a statement, the lower will be the number you circle. Please make sure that you answer EVERY ITEM and that you circle ONLY ONE number per item. This is a measure of your personal beliefs; obviously, there are no right or wrong answers.
| 1=STRONGLY DISAGREE (SD)
2=MODERATELY DISAGREE (MD) 3=SLIGHTLY DISAGREE (D) |
4=SLIGHTLY AGREE (A)
5=MODERATELY AGREE (MA) 6=STRONGLY AGREE (SA) |
|
| Number | Question | SD | MD | D | A | MA | SA |
|---|---|---|---|---|---|---|---|
| 1 | If I get sick, it is my own behavior which determines how soon I get well again. | 1 | 2 | 3 | 4 | 5 | 6 |
| 2 | No matter what I do, if I am going to get sick, I will get sick. | 1 | 2 | 3 | 4 | 5 | 6 |
| 3 | Having regular contact with my physician is the best way for me to avoid illness | 1 | 2 | 3 | 4 | 5 | 6 |
| 4 | Most things that affect my health happen to me by accident. | 1 | 2 | 3 | 4 | 5 | 6 |
| 5 | Whenever I don't feel well, I should consult a medically trained professional. | 1 | 2 | 3 | 4 | 5 | 6 |
| 6 | I am in control of my health. | 1 | 2 | 3 | 4 | 5 | 6 |
| 7 | My family has a lot to do with my becoming sick or staying healthy. | 1 | 2 | 3 | 4 | 5 | 6 |
| 8 | When I get sick, I am to blame. | 1 | 2 | 3 | 4 | 5 | 6 |
| 9 | Luck plays a big part in determining how soon I will recover from an illness. | 1 | 2 | 3 | 4 | 5 | 6 |
| 10 | Health professionals control my health. | 1 | 2 | 3 | 4 | 5 | 6 |
| 11 | My good health is largely a matter of good fortune. | 1 | 2 | 3 | 4 | 5 | 6 |
| 12 | The main thing which affects my health is what I myself do. | 1 | 2 | 3 | 4 | 5 | 6 |
| 13 | If I take care of myself, I can avoid illness. | 1 | 2 | 3 | 4 | 5 | 6 |
| 14 | Whenever I recover from an illness, it's usually because other people (for example, doctors, nurses, family, friends) have been taking good care of me. | 1 | 2 | 3 | 4 | 5 | 6 |
| 15 | No matter what I do, I 'm likely to get sick. | 1 | 2 | 3 | 4 | 5 | 6 |
| 16 | If it's meant to be, I will stay healthy. | 1 | 2 | 3 | 4 | 5 | 6 |
| 17 | If I take the right actions, I can stay healthy. | 1 | 2 | 3 | 4 | 5 | 6 |
| 18 | Regarding my health, I can only do what my doctor tells me to do. | 1 | 2 | 3 | 4 | 5 | 6 |
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