Chronic Care Programme Assessment Questionnaire
Chronic disease Schizophrenia
Date
Member surname Initials
GetMed membership nr GetMed plan
GetMed account nr Option
Patient surname Initials
Patient date of birth Dependant code
Doctor name Initials
Doctor practice number Contact number
Assessment questions
1. In general, how does the patient Excellent Very Good Fair Poor
consider his or her health: (Mark good
one)
2. How much time during the past 2
weeks...
2.1. Was the patient discouraged None A little Some of Most All of
by his or her health problems? of the of the the time of the the
time time time time
2.2. Was the patient fearful about None A little Some of Most All of
his or her future health? of the of the the time of the the
time time time time
2.3. Was the patient’s health a None A little Some of Most All of
worry in his or her life? of the of the the time of the the
time time time time
2.4. Was the patient frustrated by None A little Some of Most All of
his or her health problems? of the of the the time of the the
time time time time
3. Please circle the number that No fatigue to Severe fatigue
describes the patient’s fatigue in
the past 2 weeks: (mark one) 0 1 2 3 4 5 6
4. Please circle the number that No shortness of breath to severe shortness of breath
describes the patient’s
shortness of breath in the past 2 0 1 2 3 4 5 6
weeks: (mark one)
5. Please circle the number below No pain to severe pain
that describes the patient’s in
the past 2 weeks: 0 1 2 3 4 5 6
6. During the past week how much 0 mins Less 30 to 60 1 to 3 More
total time (for the entire week) did than mins hrs than 3
the patient spend on each of the 30 hrs
following? (Please circle one mins
number for each question.)
6.1. Stretching or strengthening 0 1 2 3 4
exercises
6.2. Walk for exercise 0 1 2 3 4
6.3. Swimming or aquatic exercise 0 1 2 3 4
6.4. Bicycling (including stationary 0 1 2 3 4
exercise bikes)
6.5. Other aerobic exercise 0 1 2 3 4
equipment (Stairmaster,
rowing, skiing machine, etc.)
6.6. Other aerobic exercise 0 1 2 3 4
6.6.1. Specify type
7. For each of the following questions,
please choose the number that
corresponds to the patient’s
confidence that he or she can do
the tasks regularly at the present
time. From not at all confident to totally confident
7.1. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the fatigue caused by his or
her disease from interfering
with the things he or she wants
to do?
7.2. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the physical discomfort or pain
of his or her disease from
interfering with the things he or
she wants to do?
7.3. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
the emotional distress caused
by his or her disease from
interfering with the things he or
she wants to do?
7.4. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can keep
any other symptoms or health
problems he or she has from
interfering with the things he or
she wants to do?
7.5. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do the
different tasks and activities
needed to manage his or her
health condition so as to
reduce his or her need to see a
doctor?
7.6. How confident does the patient 0 1 2 3 4 5 6
feel that he or she can do
things other than just taking
medication to reduce how
much his or her illness affects
his or her everyday life?
8. During the past 2 weeks, how
much... mark one
8.1. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
normal social activities with
family, friends, neighbours or
groups?
8.2. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
hobbies or recreational
activities?
8.3. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
household chores?
8.4. Has the patient’s health Not at Slightly Moderately Quite Almost
interfered with his or her all a bit totally
errands and shopping?
9. In the past 6 months, how many
times did the patient visit a doctor?
Do NOT include visits while in the times
hospital or the hospital emergency
room.
10. In the past 6 months, how many
times did the patient go to a times
hospital emergency/casualty room?
11. How many different times did the
patient stay in a hospital overnight times
or longer in the past 6 months?
12. How many total nights did the
patient spend in the hospital in the nights
past 6 months?
13. When was the patient diagnosed with > 3 years 1-3 years In the last
schizophrenia? ago ago 12 months
14. How old was the patient when 25 years
schizophrenia presented? years
15. Was the patient ever admitted to hospital Never More than a Within the
for schizophrenia? year ago last 12
months
16. How would you describe the patient’s Well Moderately Poorly
current symptoms (e.g. hallucinations)? controlled well controlled
controlled
17. When was the patient’s last psychotic > 12 6 – 12 In the last 6
episode? months months ago months
ago
18. In terms of medication use would you Very Moderately Poor
describe the patient as: compliant compliant compliance
19. In terms of lifestyle adaptation would you Very Moderately Poor
describe the patient as: compliant compliant compliance
20. How would you describe the patient’s Well Moderately Poorly
current status? controlled well controlled
controlled
21. Are there any socio-economic issues that Yes No
play a major role?
22. Is the patient’s support system: Well Some Lacking
developed support
23. Does the patient have other major Yes No
medical problems?
24. How would you assess the severity of the Mild Moderate Severe
condition?
For Office use
Reviewed by (please sign)
Date