<<Miscellaneous:Practice Letterhead>>

Partners In Health Scale
FHBHRU Flinders University June 2010	

Patient's Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>>

Assessment Date: <<Partners In Health Scale Assessment date>>
Review Date: <<Review of PIHS due>>

Patient to complete this section:

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

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

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

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 health>>

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, values and beliefs: 	<<I am able to deal with health workers to get service>>

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 dr of 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 / early warning signs>>

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

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 manage my physical activities (effect of condition)>>

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

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 my social life (effect of condition(s) )>>

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 (SNAP)>>

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