0 : Not at all confident
1
2
3
4 : Very confident
¹
0
1
2
3
4
1
Get the facts about the medication choices available to me.
2
Get the facts about the benefits of each choice.
3
Get the facts about the risks and side effects of each choice.
4
Understand the information enough to be able to make a choice.
5
Ask questions without feeling dumb.
6
Express my concerns about each choice.
7
Ask for advice.
8
Figure out the choice that best suits me.
9
Handle unwanted pressure from others in making my choice.
10
Let the clinic team know what's best for me.
11
Delay my decision, if I feel I need it.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.