Form #5 Form #5 Patient Activation Measures Survey

Attachment G: Patient Activation Measures (PAM) Survey 2

A

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

ttachment G: Patient Activation Measures (PAM) Survey

Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow

Patient Activation Measures Survey

Public reporting burden for this collection of information is estimated to average 12 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.

The Patient Activation Measure is a short questionnaire with statements about how you may feel about your health. If you are unable to complete the questions on your own, please ask for assistance. Please respond to each statement by placing a check mark in the box that most closely reflects how you feel. Please check only ONE response for each statement. Thank you!

	Strongly agree	Agree	Disagree	Strongly disagree	Not applicable
When all is said and done, I am the person who is responsible for managing my health condition.
Taking an active role in my own healthcare is the most important factor in determining my health and ability to function.
I am confident that I can take actions to prevent or minimize some symptoms or problems associated with my health condition.
I know what each of my prescribed medications do.
I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself.
I am confident I can tell my doctor concerns I have even when he or she does not ask.
I am confident that I can follow through on medical treatments I need to do at home.
I understand the nature and causes of my health condition(s).
I know the different medical treatment options available for my health condition.
I have been able to maintain the lifestyle changes for my health that I have made.
I know how to prevent further problems with my health condition.
I am confident I can come up with solutions when new situations or problems arise with my health condition.
I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress.