<PracticeLetterhead>

                                  Partners In Health Scale                                            ã FHBHRU Flinders University June 2010 	

Patient Name: <PtFullName> DOB: <PtDoB>  Record Number: <PtRecordNo>

Assessment Date: <Assessment Date> Review Date: <Review Date>

Patient to complete this section

1. Overall, what I know about my health condition(s) is:
	<My knowledge of my condition is>

Where 0 is very little and 8 is a lot	
2. Overall, what I know about the treatment, including medications of my health condition(s) is:	 <What I know about my treatment and my medications> 

Where 0 is very little and 8 is a lot	
3. I take medications or carry out the treatments asked by my doctor/health worker:	 <I take medications or treatments as asked by health team>

Where 0 is never 4-5 is sometimes and 8 is always	
4. I share in decisions made about my health condition(s) with my doctor or health worker :	<I share in decisions made about my Heath.>

Where 0 is never 4-5 is sometimes and 8 is always	
5. I am able to deal with health professionals to get services I need that fit with my culture, value and beliefs:	 <I am able to deal with health professionals to get services>

Where 0 is never 4-5 is sometimes and 8 is always	
6. I attend appointments as asked by my doctor or health worker:	<I attend appts as asked by my doctor or health worker>

Where 0 is never 4-5 is sometimes and 8 is always	
7. I keep track of my symptoms and early warning signs (e.g. BSL, weight,pain, mood)	<I keep track of my symptoms and early warning signs>

Where 0 is never 4-5 is sometimes and 8 is always	
8. I take action when early warning signs and symptoms get worse: 	<I take action when early warning signs and symptoms get wor>

Where 0 is never 4-5 is sometimes and 8 is always	
9. I manage the effect of my health condition(s) on my physical activity (i.e. walking, social)	<I manage the effect of my conditions on my Physical Activit>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well
	
10. I manage the effect of my health conditions on how I feel (i.e. emotions and spiritual well being: 	<I manage the effect of my health conditions on how I feel>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well
	
11. I manage the effect of my health condition on my social life (i.e. how I mix with other people) ; 	<I manage the effect of my health condition on my social life>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well	
12. Overall, I manage to live a healthy life (e.g. no smoking, moderate alcohol, healthy food, regular physical activity,manage stress) :	<Overall, I manage to live a healthy life>

Where 0 is Not very well, 4-5 is Fairly Well and 8 is Very Well