Form #9 Form #9 Patient Assessment of Chronic Illness Care (PACIC)

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Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

nglish Version of the Patient Assessment of Chronic Illness Care Questionnaire

Assessment of Care for Chronic Conditions
Staying healthy can be difficult when you have a chronic condition. We would like to learn about the type of help with your condition you get from your health care team. This might include your regular doctor, his or her nurse, or physician’s assistant who treats your illness. Your answers will be kept confi­dential and will not be shared with your physician or clinic.
Over the past 6months, when I received care for my chronic conditions, I was:
None of the Time		A Little of the Time		Some of the Time		Most of the Time		Always
1. Asked for my ideas when we made a treatment plan.	1		2		3		4		5
2. Given choices about treatment to think about.	1		2		3		4		5
3. Asked to talk about any problems with my medicines or their effects.	1		2		3		4		5
4. Given a written list of things I should do to improve my health.	1		2		3		4		5
5. Satisfied that my care was well organized.	1		2		3		4		5
6. Shown how what I did to take care of myself influenced my condition.	1		2		3		4		5
7 Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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 any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850. . Asked to talk about my goals in caring for my condition.	1		2		3		4		5
8. Helped to set specific goals to improve my eating or exercise.	1		2		3		4		5
9. Given a copy of my treatment plan.	1		2		3		4		5
10. Encouraged to go to a specific group or class to help me cope with my chronic condition.	1		2		3		4		5
11. Asked questions, either directly or on a survey, about my health habits.	1		2		3		4		5
12. Sure that my doctor or nurse thought about my values, beliefs, and traditions when they recommended treatments to me.	1		2		3		4		5
13. Helped to make a treatment plan that I could carry out in my daily life.	1		2		3		4		5
14. Helped to plan ahead so I could take care of my condition even in hard times.	1		2		3		4		5
15. Asked how my chronic condition affects my life.	1		2		3		4		5
16. Contacted after a visit to see how things were going.	1		2		3		4		5
17. Encouraged to attend programs in the community that could help me.	1		2		3		4		5
18. Referred to a dietitian, health educator, or counselor.	1		2		3		4		5
19. Told how my visits with other types of doctors, like an eye doctor or surgeon, helped my treatment.	1		2		3		4		5
20. Asked how my visits with other doctors were going.	 1		 2		 3		 4		 5