CMS-10723 CMS-10723.Patient Activation Assessment

Patient Activation Assessment

Being an active participant in your health and with your doctors is very important. Your QIN- QIO would like to ask you a few questions about how you manage your medical care to help us find areas where we can improve healthcare for everyone. Please take a few moments to answer the following questions. Your responses are completely private, and no personal information will be collected.

1. Please tell me how confident you are that you can identify when it is necessary for you to get medical care.

Very Confident	Confident	Somewhat Confident	Not At All Confident	Do Not Know	Prefer Not to Answer

The following are questions related to how you make healthcare decisions. The answers to these questions will help Medicare better understand how people use Medicare services.

2. How confident are you that you can identify when you are having side effects from your medications?

Very Confident	Confident	Somewhat Confident	Not At All Confident	Do Not Know	Prefer Not to Answer

3. Doctors often give instructions about how you should take care of yourself at home, like changing a bandage, taking medicines on schedule or applying ice packs. How confident are you that you can follow instructions to care for yourself at home?

Very Confident	Confident	Somewhat Confident	Not At All Confident	Do Not Know	Prefer Not to Answer

4. Doctors also often give instructions about changing your habits or lifestyle, such as changing your diet, or getting regular exercise in order to control blood pressure. How confident are you that [you] can follow these recommendations?

   Very Confident	Confident	Somewhat Confident	Not At All Confident	Do Not Know	Prefer Not to Answer

5. How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate?

Very Likely	Likely	Unlikely	Very Unlikely	Do Not Know	Prefer Not to Answer

6. How likely are you to tell your doctor when you disagree with him or her?

Very Likely	Likely	Unlikely	Very Unlikely	Do Not Know	Prefer Not to Answer

7. Do you always, usually, sometimes or never read about health conditions in newspapers, magazines or on the internet?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

8. Do you always, sometimes, usually, or never read information about a new prescription, such as side effects and precautions?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

9. Do you always, sometimes, usually or never bring with you to your doctor’s visits a list of questions or concerns you want to cover?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

10. Do you always, sometimes, usually or never leave your doctor’s office feeling that all of your concerns or questions have been fully answered?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

11. Do you always, usually, sometimes or never take a list of all your prescribed medicines to your doctor’s visits?

    Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

12. Do you always, sometimes, usually or never make sure you understand the results of any medical test or procedure such as an x- ray, blood test, or EKG for heart conditions?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

13. Do you always, usually, sometimes or never talk with your doctor or other medical person about your options if you need tests, follow-up care, or a referral for care by a medical specialist?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

14. My doctor listens to what I have to say about my symptoms and concerns. Does that always, sometimes, usually, or never happen?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

15. My doctor explains things to me in terms that I can easily understand. Does that always, sometimes, usually or never happen?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

16. I can call my doctor’s office to get medical advice when I need it. Does that always, sometimes, usually, or never happen?

Always	Usually	Sometimes	Never	Do Not Know	Prefer Not to Answer

Thank you for taking the time to complete this questionnaire. Your input is valuable.