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The statements below ask you about managing your health after stroke.

Take a break
between sections if needed. You may ask someone to help you complete the
questionnaire. There are no right or wrong answers.
Please read the following statements carefully. Thinking about the last month, indicate
how true or false statements 1-9 are for you. Tick or cross in the box which most closely
represents your view.
1. The effects of stroke mean that I cannot manage my recovery and health
2. When things do not go well with my stroke, it is hard to stay positive
3. It is not up to me to decide what the best ways to manage my stroke are
4. The physical effects of stroke mean that I cannot manage my health as I would like
5. It is hard to be motivated to seek out solutions to problems relating to stroke
6. I am not sure what signs or symptoms might mean my health is changing
7. My problems with communication mean that I cannot manage my health as I would
like
8. Whatever I do, I will not improve my condition
9. The efforts I take to manage my health have a positive effect
This section asks you to think about communicating with health care professionals.
Thinking about the last month, indicate how true or false these statements are for you
1. I find it difficult to tell health care professionals what I want or need
2. I work out ways of managing my health following stroke together with health care
professionals
3. I am confident that health care professionals can answer my questions
4. I feel confident at discussing any advice I dont understand with Doctors
5. I feel confident at getting the information I need from Health care professionals
6. I know how to get help if I am concerned about my condition
This section asks you about some of the things you might do to manage your health.
Thinking about the last month, indicate how true or false these statements are for you.
1. I plan my day so I can get things done without being tired
2. I feel confident asking family members to help me do things important to my health
3. I manage things related to stroke as well as other people with stroke
4. I try different ways of doing things, until I find out what works for me
5. Ideas and things that work for other people with stroke are helpful to my recovery
6. I have useful information or advice to give to others regarding managing after stroke
7. I feel comfortable asking friends to help me do things important to my health

The last section, asks you to think about how health professionals might assist you to
manage your health. Thinking about the last month, please indicate how true or false
these statements are for you
1. I am concerned that the things I do to manage stroke may cause harm if not guided by
health care professionals
2. I cannot alter what my health care professionals decide to do about my stroke
3. Following advice from health care professionals is the only way I
4. will manage stroke
5. I always follow professional advice about my health, to the letter
6. Constant professional advice would help me to manage stroke

Energy

Family Roles

1. I felt tired most of the time.

4. I didn't join in activities just for fun


with my family.

2. I had to stop and rest during the day.


5. I felt I was a burden to my family.
3. I was too tired to do what I wanted to
do.
6. My physical condition interfered with
my personal life.
Language

Mobility

1. Did you have trouble speaking? For 1. Did you have trouble walking? (If
example, get stuck, stutter, stammer, or
patient can't walk, go to question 4 and
slur your words?
score questions 2-3 as 1.)
2. Did you have trouble speaking clearly 2. Did you lose your balance when
enough to use the telephone?
bending over to or reaching for
something?
3. Did other people have trouble in
understanding what you said?
3. Did you have trouble climbing stairs?
4. Did you have trouble climbing the word 4. Did you have to stop and rest more than
you wanted to say?
you would like when walking or using
a wheelchair?
5. Did you have to repeat yourself so
others could understand you?
5. Did you have trouble with standing?
6. Did you have trouble getting out of a
chair?
Mood

Personality

1. I was discouraged about my future.

1. I was irritable.

2. I wasn't interested in other people or


activities.
3. I felt withdrawn from other people.

2. I was inpatient with others.


3. My personality has changed.

4. I had little confidence in myself.


5. I was not interested in food.
Self care

Social roles

1. Did you need help preparing food?

1. I didn't go out as often as I would like.

2. Did you need help eating? For example, 2. I did my hobbies and recreation for
cutting food or preparing food?
shorter periods of time than I would
like.
3. Did you need help getting dressed? For
example, putting on socks or shoes, 3. I didn't see as many of my friends as I
buttoning buttons, or zipping?
would like.
4. Did you need help taking a bath or a 4. I had sex less often than I would like.
shower?
5. My physical condition interfered with
5. Did you need help to use the toilet?
my social life.
Thinking

Upper extremity function

1. It was hard for me to concentrate.

1. Did you have trouble writing or typing?

2. I had trouble remembering things.

2. Did you have trouble putting on socks?

3. I had to write things down to remember 3. Did you


them.
buttons?

have

trouble

buttoning

4. Did you have trouble zipping a zipper?


5. Did you have trouble opening a jar?
Vision

Work/Productivity

1. Did you have trouble seeing the 1. Did you have trouble doing daily work
television well enough to enjoy a show?
around the house?
2. Did you have trouble reaching things 2. Did you have trouble finishing jobs that
because of poor eyesight?
you started?
3. Did you have trouble seeing things off 3. Did you have trouble doing the work
to one side?
you used to do?

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