Psychosocial factors | Question/item | Possible responses |
---|---|---|
Mental health domain | ||
History of substance abuse | Has the patient ever had a history of substance abuse? | • No • Yes |
Depression or anxiety | Are there signs/symptoms present for depression or anxiety problems? | • No • Yes |
Social support domain | ||
Relationship status | What is the patient’s relationship status? | • Domestic partner • Married • Divorced • Single • Widowed • Separated |
Living alone | With whom does the patient live? | • Lives alone • Lives with parents • Spouse • Children • Significant other • Friend • Relative • Other |
Frequency of social support | What is the level of involvement of family and friend on a regular basis? | • Daily • Weekly • Monthly • Less frequently than monthly |
Independence domain | ||
Impaired memory | Does the patient appear to have a problem with the following? | Short term memory • No • Yes Long term memory • No • Yes |
Current employment | Current employment? | • Employed full-time • Employed part-time • Retired • Medical leave of absence • Unemployed-by choice • Unemployed disabled • Unemployed-looking for work • Other |
Mobility impairment | Ambulatory assistance? | • None • Cane/crutch • Walker or • Manual wheelchair • Electric wheelchair • Limb prosthesis |
Type of housing | Living status? | • Home • Condo • Mobile home • Apartment • Rents house • Assisted living • Homeless • Public housing shelter • Long term care facility(SNF) • Acute rehabilitation center • Correctional facility • Adult family home • Adult group home |
Ease of adherence domain | ||
Coming to dialysis | Over the past month, how easy or difficult has it been for you to come to each hemodialysis treatment? | • N/A • Very easy • Somewhat easy • Neither easy nor difficult • Somewhat difficult • Very difficult |
Completing dialysis sessions | Over the past month, how easy or difficult has it been for you to complete the full-prescribed hemodialysis treatment time? | • N/A • Very easy • Somewhat easy • Neither easy nor difficult • Somewhat difficult • Very difficult |
Taking medications | Over the past month, how easy or difficult has it been for you to take medications as prescribed? | • N/A • Very easy • Somewhat easy • Neither easy nor difficult • Somewhat difficult • Very difficult |
Adhering to dietary restrictions | Over the past month, how easy or difficult has it been for you to follow dietary restrictions? | • N/A • Very easy • Somewhat easy • Neither easy nor difficult • Somewhat difficult • Very difficult |
Adhering to fluid restrictions | Over the past month, how easy or difficult has it been for you to follow fluid restrictions? | • N/A • Very easy • Somewhat easy • Neither easy nor difficult • Somewhat difficult • Very difficult |