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)
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SD |
MD |
D |
A |
MA |
SA |
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1. If I get sick‚ it is my own behavior which determines how soon I get well again. |
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2. No matter what I do‚ if I am going to get sick‚ I will get sick. |
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3. having regular contact with my physician is the best way for me to avoid illness. |
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4. Most things that affect my health happen to me by accident. |
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5. Whenever I don’t feel well‚ I should consult a medically trained professional. |
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6. I am in control of my health. |
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7. My family has a lot to do with my becoming sick or staying healthy. |
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8. When I get sick‚ I am to blame. |
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9. Luck plays a big part in determining how soon I will recover from an illness. |
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10. Health professionals control my health. |
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11. My good health is largely a matter of good fortune. |
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12. The main thing which affects my health is what I myself do. |
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13. If I take care of myself‚ I can avoid illness. |
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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. |
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15. No matter what I do‚ I ‘m likely to get sick. |
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16. If it’s meant to be‚ I will stay healthy. |
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17. 17 If I take the right actions‚ I can stay healthy. |
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18. Regarding my health‚ I can only do what my doctor tells me to do. |
http://www.vanderbilt.edu/nursing/kwallston/mhlcforma.htm
Form B
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)
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SD |
MD |
D |
A |
MA |
SA |
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1. If I become sick‚ I have the power to make myself well again. |
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2. Often I feel that no matter what I do‚ if I am going to get sick‚ I will get sick. |
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3. If I see an excellent doctor regularly‚ I am less likely to have health problems. |
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4. It seems that my health is greatly influenced by accidental happenings. |
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5. I can only maintain my health by consulting health professionals. |
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6. I am directly responsible for my health. |
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7. Other people play a big part in whether I stay healthy or become sick. |
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8. Whatever goes wrong with my health is my own fault. |
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9. When I am sick‚ I just have to let nature run its course. |
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10. Health professionals keep me healthy. |
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11. When I stay healthy‚ I’m just plain lucky. |
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12. My physical well-being depends on how well I take care of myself. |
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13. When I feel ill‚ I know it is because I have not been taking care of myself properly. |
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14. The type of care I receive from other people is what is responsible for how well I recover from an illness. |
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15. Even when I take care of myself‚ it’s easy to get sick. |
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16. When I become ill‚ it’s a matter of fate. |
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17. I can pretty much stay healthy by taking good care of myself. |
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18. Following doctor’s orders to the letter is the best way for me to stay healthy. |
Form C
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)
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SD |
MD |
D |
A |
MA |
SA |
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1. If my condition worsens‚ it is my own behavior which determines how soon I will feel better again. |
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2. As to my condition‚ what will be will be. |
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3. If I see my doctor regularly‚ I am less likely to have problems with my condition. |
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4. Most things that affect my condition happen to me by chance. |
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5. Whenever my condition worsens‚ I should consult a medically trained professional. |
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6. I am directly responsible for my condition getting better or worse. |
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7. Other people play a big role in whether my condition improves‚ stays the same‚ or gets worse. |
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8. Whatever goes wrong with my condition is my own fault |
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9. Luck plays a big part in determining how my condition improves. |
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10. In order for my condition to improve‚ it is up to other people to see that the right things happen. |
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11. Whatever improvement occurs with my condition is largely a matter of good fortune. |
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12. The main thing which affects my condition is what I myself do. |
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13. I deserve the credit when my condition improves and the blame when it gets worse. |
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14. Following doctor’s orders to the letter is the best way to keep my condition from getting any worse. |
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15. If my condition worsens‚ it’s a matter of fate. |
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16. If I am lucky‚ my condition will get better. |
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17. If my condition takes a turn for the worse‚ it is because I have not been taking proper care of myself. |
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18. The type of help I receive from other people determines how soon my condition improves. |