Living with Chronic Illness

Do you have more than one long-term health condition?

Choose one:

• Yes
• No

Which long-term condition or conditions do you have?

Open answer

How much does each of the following apply to you?

• Difficulty managing everyday activities
• Worry about my future health
• Stress caused by the cost of my care
• Feeling cut off from friends and family

For each row: choose one:

• Not at all
• A little
• Moderately
• Quite a lot
• Very much

Are you currently following a formal treatment plan for your condition or conditions?

Choose one:

• Yes
• No

What does your treatment plan involve?

Condition: Shown to people with a treatment plan

Open answer

Does your treatment plan keep your symptoms under control?

Condition: Shown to people with a treatment plan

Choose one:

• Yes
• Somewhat
• No

How well does each type of treatment work for you, from 1 (not at all) to 10 (extremely well)?

• Medication
• Physiotherapy
• Counselling or psychotherapy

For each row: choose one from a list:

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• Not used

Who are the main people supporting you? Select all that apply.

Choose any that apply:

• Family
• Friends
• Health professionals
• Support groups
• Other
• No one

In what ways have these people helped you manage your condition?

Condition: Shown when at least one source of support is selected

Open answer