Page 40 - THE PERCEPT STUDY Illness Perceptions in Physiotherapy Edwin de Raaij

Chapter 2
Appendix A: The Brief Illness Perception Questionnaire 4
For the following questions, please circle the number that best corresponds to your views:
1. How much does your illness affect your life?
0 1 2 3 4 5 6 7 8 9 10
No affect at all Severely affects my life ____________________________________________________________________________________________
2. How long do you think your illness will continue?
0 1 2 3 4 5 6 7 8 9 10
A very short time Forever ____________________________________________________________________________________________
3. How much control do you feel you have over your illness?
0 1 2 3 4 5 6 7 8 9 10
Absolutely no control Extreme amount of control ____________________________________________________________________________________________
4. How much do you think your treatment can help your illness?
0 1 2 3 4 5 6 7 8 9 10
Not at all Extremely helpful ____________________________________________________________________________________________
5. How much do you experience symptoms from your illness?
0 1 2 3 4 5 6 7 8 9 10
No symptoms at all Many severe symptoms ____________________________________________________________________________________________
6. How concerned are you about your illness?
0 1 2 3 4 5 6 7 8 9 10
Not at all concerned Extremely concerned ____________________________________________________________________________________________
7. How well do you feel you understand your illness?
0 1 2 3 4 5 6 7 8 9 10
Don’t understand at all Understand very clearly ____________________________________________________________________________________________
8. How much does your illness affect you emotionally? (e.g. does it make you angry, scared, upset or depressed?)
0 1 2 3 4 5 6 7 8 9 10 Not at all affected emotionally Extremely affected emotionally
____________________________________________________________________________________________
9. Please list in rank-order the three most important factors that you believe caused your illness. The most important causes for me:
1. ............................................ 2. ............................................ 3. ............................................
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