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) |
|
| Number | Question | SD | MD | D | A | MA | SA |
|---|---|---|---|---|---|---|---|
| 1 | If I become sick, I have the power to make myself well again. | 1 | 2 | 3 | 4 | 5 | 6 |
| 2 | Often I feel that no matter what I do, if I am going to get sick, I will get sick. | 1 | 2 | 3 | 4 | 5 | 6 |
| 3 | If I see an excellent doctor regularly, I am less likely to have health problems. | 1 | 2 | 3 | 4 | 5 | 6 |
| 4 | It seems that my health is greatly influenced by accidental happenings. | 1 | 2 | 3 | 4 | 5 | 6 |
| 5 | I can only maintain my health by consulting health professionals. | 1 | 2 | 3 | 4 | 5 | 6 |
| 6 | I am directly responsible for my health. | 1 | 2 | 3 | 4 | 5 | 6 |
| 7 | Other people play a big part in whether I stay healthy or become sick. | 1 | 2 | 3 | 4 | 5 | 6 |
| 8 | Whatever goes wrong with my health is my own fault. | 1 | 2 | 3 | 4 | 5 | 6 |
| 9 | When I am sick, I just have to let nature run its course. | 1 | 2 | 3 | 4 | 5 | 6 |
| 10 | Health professionals keep me healthy. | 1 | 2 | 3 | 4 | 5 | 6 |
| 11 | When I stay healthy, I'm just plain lucky. | 1 | 2 | 3 | 4 | 5 | 6 |
| 12 | My physical well-being depends on how well I take care of myself. | 1 | 2 | 3 | 4 | 5 | 6 |
| 13 | When I feel ill, I know it is because I have not been taking care of myself properly. | 1 | 2 | 3 | 4 | 5 | 6 |
| 14 | The type of care I receive from other people is what is responsible for how well I recover from an illness. | 1 | 2 | 3 | 4 | 5 | 6 |
| 15 | Even when I take care of myself, it's easy to get sick. | 1 | 2 | 3 | 4 | 5 | 6 |
| 16 | When I become ill, it's a matter of fate. | 1 | 2 | 3 | 4 | 5 | 6 |
| 17 | I can pretty much stay healthy by taking good care of myself. | 1 | 2 | 3 | 4 | 5 | 6 |
| 18 | Following doctor's orders to the letter is the best way for me to stay healthy. | 1 | 2 | 3 | 4 | 5 | 6 |
CONNECT WITH #VUSN
