Form C
Instructions: Each item below is a belief statement about your medical condition with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree (1) to strongly agree (6). For each item we would like you to circle the number that represents the extent to which you agree or disagree with that statement. The more you agree with a statement, the higher will be the number you circle. The more you disagree with a statement, the lower will be the number you circle. Please make sure that you answer EVERY ITEM and that you circle ONLY ONE number per item. This is a measure of your personal beliefs; obviously, there are no right or wrong answers.

1=STRONGLY DISAGREE (SD)
2=MODERATELY DISAGREE (MD)
3=SLIGHTLY DISAGREE (D)		 4=SLIGHTLY AGREE (A)
5=MODERATELY AGREE (MA)
6=STRONGLY AGREE (SA)
  SD MD D A MA SA

1

 If my condition worsens, it is my own behavior which determines how soon I will feel better again. 1 2 3 4 5 6
2 As to my condition, what will be will be. 1 2 3 4 5 6
3 If I see my doctor regularly, I am less likely to have problems with my condition. 1 2 3 4 5 6
4 Most things that affect my condition happen to me by chance. 1 2 3 4 5 6
5 Whenever my condition worsens, I should consult a medically trained professional. 1 2 3 4 5 6
6 I am directly responsible for my condition getting better or worse. 1 2 3 4 5 6
7 Other people play a big role in whether my condition improves, stays the same, or gets worse. 1 2 3 4 5 6
8 Whatever goes wrong with my condition is my own fault. 1 2 3 4 5 6
9 Luck plays a big part in determining how my condition improves. 1 2 3 4 5 6
10 In order for my condition to improve, it is up to other people to see that the right things happen. 1 2 3 4 5 6
11 Whatever improvement occurs with my condition is largely a matter of good fortune. 1 2 3 4 5 6
12 The main thing which affects my condition is what I myself do. 1 2 3 4 5 6
13 I deserve the credit when my condition improves and the blame when it gets worse. 1 2 3 4 5 6
14 Following doctor's orders to the letter is the best way to keep my condition from getting any worse. 1 2 3 4 5 6
15 If my condition worsens, it's a matter of fate. 1 2 3 4 5 6
16 If I am lucky, my condition will get better. 1 2 3 4 5 6
17 If my condition takes a turn for the worse, it is because I have not been taking proper care of myself. 1 2 3 4 5 6
18 The type of help I receive from other people determines how soon my condition improves. 1 2 3 4 5 6

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