DIRECTIONS

Questionnaire

Patients with chronic health conditions need to have special skills and do special tasks to stay healthy.

On the following pages, please check the box underneath the answers that describe you most.

If you do not understand a question, just ask for help. We’re here to help you

TAKERS Master’s Paper N’Djamina Johnson 57 | P a g e Site ID: Patient ID: Date: Section 1 :

How often have you done the following things?

Please check the box that tells how often you have done each thing in the PAST 3 MONTHS.

In the past 3 months … Never Almost

Never Sometimes Almost Always Always Not Needed for my care 1. How often did you make an effort to understand what

your doctor told you?

□ □ □ □ □ □

2. How often did you take your medicines on your own? □ □ □ □ □ □

3. How often did you ask your doctor or nurse questions about your illness, medicines or medical care?

□ □ □ □ □ □

4. How often did you make your own appointments? □ □ □ □ □ □

5. How often did you need someone to remind you to take your medicines?

□ □ □ □ □ □

6. How often did you use things likes pillboxes, schedules, or alarm clocks to help you take your medicines when you were supposed to?

□ □ □ □ □ □

7. How often did you use the internet, books or other guides to find out more about your illness?

□ □ □ □ □ □

8. How often did you forget to take your medicines? □ □ □ □ □ □

9. How often did you work with your doctor to take care of new health problems that came up?

□ □ □ □ □ □

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Some patients know a lot about their health and some patients don't. How much do you know?

Please check the answer that best describes how much you feel you know TODAY.

Nothing Not Much A little Some A Lot Not Needed for my care

10. How much do you know about your illness? □ □ □ □ □ □

11. How much do you know about taking care of your illness? □ □ □ □ □ □

12. How much do you know about what will happen if you don't take your medicines?

□ □ □ □ □ □

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Site ID: Patient ID: Date:

Section 3:

Some patients may find it hard to do certain things. How easy or hard is it for you to do the following things?

Please check the answer that best describes how you feel TODAY.

Very Hard Somewhat Hard Neither Hard nor Easy Somewhat Easy Very Easy Not Needed for my care

13. How easy or hard is it to talk to your doctor? □ □ □ □ □ □

14. How easy or hard is it to make a plan with your doctor to care for your health?

□ □ □ □ □ □

15. How easy or hard is it to see your doctor by yourself?

□ □ □ □ □ □

16. How easy or hard is it to take your medicines like you are supposed to?

□ □ □ □ □ □

17. How easy or hard is it to take care of yourself? □ □ □ □ □ □

18. How easy or hard do you think it will be to move from pediatric to adult care?

□ □ □ □ □ □

TAKERS Master’s Paper N’Djamina Johnson 60 | P a g e Morisky 8 General Medication Adherence Scale

You indicated that you are taking medication for your (identify health concern, such as “high blood pressure”). Individuals have identified several issues regarding their medication-taking behavior and we are interested in your experiences. There is no right or wrong answer. Please answer each question based on your personal experience with your [health concern] medication. Interviewers may self identify regarding difficulties they may experience concerning

medication-taking behavior.

(Please circle the correct number) No=0 Yes=1 1. Do you sometimes forget to take your [health concern] pills?

2. People sometimes miss taking their medications for reasons other than forgetting. Thinking over the past two weeks, were there any days when you did not take your [health concern] medicine?

3. Have you ever cut back or stopped taking your medication without telling your doctor, because you felt worse when you took it?

4. When you travel or leave home, do you sometimes forget to bring along your [health concern] medication?

5. Did you take your [health concern] medicine yesterday?

6. When you feel like your [health concern] is under control, do you sometimes stop taking your medicine?

7. Taking medication everyday is a real inconvenience for some people. Do you ever feel hassled about sticking to your blood pressure treatment plan?

8. How often do you have difficulty remembering to take all your medications? (Please circle the correct number)

Never/Rarely……….0

Once in a while……….1

Sometimes………....2

Usually……….3

All the time………..4

Source: Morisky DE, Ang A, Krousel-Wood M, Ward H. Predictive Validity of a Medication Adherence Measure for Hypertension Control. Journal of Clinical Hypertension 2008; 10(5):348-354.

For additional information, contact: Donald E. Morisky, Sc.D., M.S.P.H., Sc.M., e-mail: [email protected]; phone: (310) 825-8508

TAKERS Master’s Paper N’Djamina Johnson 61 | P a g e Medical Passport Survey (completed by patient)

Q1 What is your transition ID number?

Q2 In the last 3 months, how many doctor appointments have you had?

Q3 At how many of these doctor appointments did you show someone your medical passport? Q4 In the last 3 months, how many times have you gone to the emergency room?

Q5 Out of those times you have gone to the emergency room, how many times did you show someone your medical passport?

Q6 Where have you used your medical passport? (please mark all that apply)

 showed it to a doctor and/or nurse when I had an appointment

 showed it to a doctor and/or nurse when I was in the emergency room

 showed it to a paramedic when I had an emergency and the ambulance was called

 used it at home to learn about my medicines

 used it in the community as an identification (ID) card

 I have not used my medical passport during the last 3 months.

Q7 Have you ever used your medical passport to do any of the following: (please mark all that apply)

 Learn the name of your health condition

 Learn the name of your medicine(s)

 Learn when you are supposed to take your medicine(s)

 Learn why you take each of your medicine(s)

 Get your medical provider's phone number

 Learn the name of your health insurance

 Other (please tell us what other information you used your medical passport to obtain) ____________________

 I have not used my medical passport during the last 3 months. Q8 Do you carry your medical passport with you?

 Yes, I always have it with me

 Sometimes I carry it with me

 No, I never carry it with me

Q9 During an average week, how many days do you carry your medical passport with you?

 0  1  2  3  4  5  6  7

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Q10 If you DO NOT carry your medical passport with you everyday, please mark all of the reasons below that explain why.

 I don't have a wallet or purse to carry it in

 I don't like the medical passport

 I don't want other people to see it

 Someone else carries it for me

 I lost it

 I don't know why I don't carry it

 I carry it with me everyday

Q11 Has your medical passport been useful?

 Yes

 No

Answer If Has your medical passport been useful? Yes Is Selected Q12 If YES, please tell us how it has been useful.

Answer If Has your medical passport been useful? No Is Selected Q13 If NO, please tell us why it hasn't been useful.

Q14 Would you recommend this medical passport to young people like yourself who also have a medical condition?

 Yes

 No

Answer If Would you recommend this medical passport to young people... Yes Is Selected Q15 If YES, please tell us why you would recommend it.

Answer If Would you recommend this medical passport to young people... No Is Selected Q16 If NO, please tell us why you would not recommend it.

TAKERS Master’s Paper N’Djamina Johnson 63 | P a g e (Davis et al., 2006)

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Job Aid

The Newest Vital Sign Assessment

The content for this material was excerpted from The Newest Vital Sign—A Health Literacy Assessment Tool website available at: http://www.newestvitalsign.org/nvs-resources.aspx

The views expressed in these documents, Web sites, or other products do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Health Resources and Services

Administration, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Module 2: Health Literacy 1 Vital Sign Assessment: Job

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Job Aid

Module 2: Health Literacy 2 Vital Sign

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