Form No number No number Illness Management Questionnaire

Form Approved

OMB No.

Expiration Date:

Attachment 24

Stress and Coping Questionnaires

<<Illness Management Questionnaire>>

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or an other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Illness Management Questionnaire (IMQ)

Date: ____________ I.D. Number: ____________

Dealing With Your Illness (IMQ)

Listed below are a number of ways in which people may deal with their illness. These include things that they feel and tell themselves, and things that they do or avoid doing. Think of your own experience of being ill, and say to what extent you respond to your illness in the way described by each of the statements below.

There are no right or wrong answers: say what is TRUE FOR YOU. Your feelings and the thing you do may vary from time to time. In your answers, describe your overall response to your illness DURING THE PAST MONTH.

For each statement, fill in a number where:

1 = Never

2 = Almost Never

3 = Sometimes

4 = Quite often

5 = Always

_____ 1. I make myself carry on, despite how I feel.

_____ 2. I try to do the things I did before my illness.

_____ 3. I avoid emotionally stressful situations.

_____ 4. I plan my activities carefully, to take account of my limitations.

_____ 5. I deliberately break “the rules” to give my spirits a lift.

_____ 6. I tell myself I can overcome the fatigue.

_____ 7. I tell myself I don’t feel too bad.

_____ 8. You have to realize you are helpless in the face of this illness.

_____ 9. I organize my life to avoid overdoing things.

_____ 10. I push myself to stay active.

_____ 11. I tell myself I can’t let my symptoms stand in the way of what I want to do.

_____ 12. I try not to think about my illness.

_____ 13. I think a great deal about my symptoms.

_____ 14. I try to strike a balance between resting and being active.

_____ 15. You have to realize that your life is ruled by the illness.

_____ 16. I try not to pay attention to my symptoms.

_____ 17. I find out as much as I can about this illness.

_____ 18. From my own experience, I feel I know what is best for me to do.

_____ 19. You have to give up trying to lead a normal life.

_____ 20. My symptoms are always at the back of my mind.

1 = Never

2 = Almost Never

3 = Sometimes

4 = Quite often

5 = Always

_____ 21. I manage my time so that I don’t have to do too much in one day.

_____ 22. I do something regardless of how it affects my symptoms.

_____ 23. I look for new information about this illness.

_____ 24. I try to pretend my symptoms aren’t there.

_____ 25. I try to make my life stress-free.

_____ 26. I push myself until I can do no more.

_____ 27. I plan my day so that there are times when I am active and times when I can rest.

_____ 28. I control my negative feelings.

_____ 29. I look up medical information.

_____ 30. Even if I feel ill, I just keep going.

_____ 31. I try to ignore my symptoms.

_____ 32. My illness is the most significant think in my life.

_____ 33. I am constantly aware of how I am feeling.

_____ 34. Even though unwell, I just go on as if I was feeling okay.

_____ 35. I do something I want to do even though I know I will feel worse after.

_____ 36. I make sure that I don’t overdo things.

_____ 37. I follow the advice of others.

_____ 38. I select an approach to my illness and preserve with that.

_____ 39. I pay close attention to how well or badly I am feeling.

_____ 40. I read books and articles about my illness.

_____ 41. I spend a lot of time thinking about my illness..

_____ 42. I try to control how much stress there is in my life.

_____ 43. I try to keep some energy “in reserve” in case I need it.

_____ 44. I take a chance and do something, even though I may feel worse later.

_____ 45. I try anything I hear of that might help me to get better.