The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient
Questionnaires
Six Month Follow
Up
Page 1 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Section: Six Month Follow Up
Patient identification number
Date of six month follow up
D
D
M
M
Y
Y
Y
Y
GP Practice Number
Researcher Initials
Signature of Assessor
Page 2 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 1: Employment, Housing, Health and Leisure (EHHaL)
Question 1: Living arrangements
1a. Do you live with anyone? (Please tick as many that apply to you)
Partner or spouse
1 [
]
Children (under 18)
2 [
]
Other adults including family and friends
3 [
]
Live alone
4 [
]
Parents home
5 [
]
Other family carers home
6 [
]
Lives independently, without any paid support
7 [
]
Supported group living (shared tenancy, with paid support)
8 [
]
Supported living – individual (single tenancy, with paid support)
9 [
]
Residential care (registered home)
10 [
]
Nursing home
11 [
]
NHS accommodation
12 [
]
Other accommodation…..……………………………………………………....
13 [
]
1b.Please tick the type of accommodation you live in (please tick one)
2.
If you live in supported accommodation or residential care how much support do you get
each week? (Please tick one)
Part-time support (less than daily)
1 [
]
Part-time support (daily)
2 [
]
24 hour support, sleep-in nights
3 [
]
24 hour support, including wake at night
4 [
]
Organisation providing support package………………………………………………………..
Page 3 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
3.
Are you in paid employment? Are you in education, training or retired? What employment
type/s do you have? (Please tick as many that apply to you)
None
0 [
]
Part time paid employment (30 hours / week or less)
1 [
]
Full time paid employment (more than 30 hours / week)
2 [
]
Paid employment with paid support / employment training
3 [
]
Employed, but only paid up to the allowed limit without affecting benefits
4 [
]
Voluntary work
5 [
]
Education including school, college, or other training
6 [
]
Internship
7 [
]
Looking after home and family
8[
]
Retired from paid work
9[
]
10 [
]
Other, please give details….………………..…………………………………..
4.
Is there anyone who helps you with daily activities like shopping, cooking, cleaning,
looking after yourself or leisure activities? (Please tick)
Yes (Please complete the table below)
1 [
]
No (if no please go to question 5)
0 [
]
If yes, please complete the table below for all of the people who help you with daily activities like
shopping, cooking, cleaning, looking after yourself or leisure activities. Please tick as many that
apply to you.
Page 4 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Who helps you
with daily
activities?
(please tick)
Is this person employed? (Please tick)
No
Friend
Patient Identification Number
[
Thinking about a
typical week in the
last 6 months, how
many hours of care
or support were
provided by this
person?
Thinking about a typical week
in the last 6 months,
approximately how many
hours per week does this
person spend helping you with
the following activities?
]
Shopping for food
YES [
]
Part time paid employment
(30 hours / week or less)
[
Full time paid employment
(more than 30 hours / week) [
NO [
]
_____hours per
week
________ hours per week
Cooking
]
]
_______ hours per week
Retired from paid work
[
]
Exercising or playing sports
In education
[
]
________ hours per week
Other, please give details
Other leisure activities
…………………………………..…………………
Partner or
spouse
YES [
NO [
]
]
No
[
_______ hours per week
]
Shopping for food
Part time paid employment
(30 hours / week or less)
[
]
Full time paid employment
(more than 30 hours / week) [
]
Retired from paid work
[
]
In education
[
]
_____hours per
week
________ hours per week
Cooking
_______ hours per week
Exercising or playing sports
________ hours per week
Other, please give details
Other leisure activities
…………………………………..…………………
_______ hours per week
Page 5 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Who helps you
with daily
activities?
(please tick)
Mental health
worker
Patient Identification Number
Is this person employed? (Please tick)
No
[
NO [
]
]
Thinking about a typical week
in the last 6 months,
approximately how many
hours per week does this
person spend helping you with
the following activities?
]
Shopping for food
Part time paid employment
(30 hours / week or less)
[
YES [
Thinking about a
typical week in the
last 6 months, how
many hours of care
or support were
provided by this
person?
]
Full time paid employment
(more than 30 hours / week) [
]
Retired from paid work
[
]
In education
[
]
_____hours per
week
________ hours per week
Cooking
_______ hours per week
Exercising or playing sports
________ hours per week
Other, please give details
Other leisure activities
…………………………………..…………………
_______ hours per week
Support worker
No
[
]
Shopping for food
YES [
NO [
]
Part time paid employment
(30 hours / week or less)
[
]
Full time paid employment
(more than 30 hours / week) [
]
Retired from paid work
[
]
In education
[
]
_____hours per
week
________ hours per week
Cooking
]
_______ hours per week
Exercising or playing sports
________ hours per week
Other, please give details
Other leisure activities
…………………………………..…………………
_______ hours per week
Page 6 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Who helps you
with daily
activities?
(please tick)
Family Member
Patient Identification Number
Is this person employed? (Please tick)
No
[
Thinking about a
typical week in the
last 6 months, how
many hours of care
or support were
provided by this
person?
Thinking about a typical week
in the last 6 months,
approximately how many
hours per week does this
person spend helping you with
the following activities?
]
Shopping for food
YES [
NO [
]
Part time paid employment
(30 hours / week or less)
[
]
Full time paid employment
(more than 30 hours / week) [
]
Retired from paid work
[
]
In education
[
]
_____hours per
week
________ hours per week
Cooking
]
_______ hours per week
Exercising or playing sports
If YES please
give details
________ hours per week
Other, please give details
Other leisure activities
………………
…………………………………..…………………
_______ hours per week
………………
No
Other
[
]
Shopping for food
YES [
NO [
]
Part time paid employment
(30 hours / week or less)
[
]
Full time paid employment
(more than 30 hours / week) [
]
_____hours per
week
________ hours per week
Cooking
]
_______ hours per week
Retired from paid work
[
]
In education
[
]
Exercising or playing sports
If YES please
give details
________ hours per week
Other, please give details
Other leisure activities
………………
…………………………………..…………………
_______ hours per week
……………….
Page 7 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
5.
Patient Identification Number
Have you accessed stop smoking services in the last 6 months? (Please tick)
Yes
1 [
]
No (if no please go to question 8)
0 [
]
Not Applicable (please go to question 8)
2 [
]
6.
Which of the following stop smoking services have you used? (Please tick as many that
apply to you). Please give details of the total number of contacts (in the last 6 months) in the box
provided.
One-to-one meetings with a trained advisor
0 [
]
Group meetings with a trained advisor
1 [
]
Quit smoking application (app) on your phone or computer
2 [
]
Quit kit (a box with practical tools and advice)
3 [
]
Other, please give details………………………………………………………….
4 [
]
7.
In the last 6 months, have you been prescribed or used any nicotine replacement therapies
(NRT) such as gum, patches, inhalers, lozenges’, spray or e-cigarettes?
Yes
1 [
]
No
0 [
]
If yes, please complete below for all of the types of nicotine replacement therapies (NRT) you have
used in the last 6 months. Leave blank if you have not used that type of NRT
Type of
nicotine
replacement
therapy (NRT)
For how
many
months have
you taken
the NRT?
Gum
How often do you buy or have a
prescription filled for? Please tick one
Once a week
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Do you, your family or
carer pay for the NRT,
or is it free to you on
the NHS? Please tick
one
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
you pay per month in
Less than once every two months [ ]
£ and p: £_ _ _. _ _
Only got it once
[ ]
Page 8 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patches
Patient Identification Number
Once a week
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
you pay per month in £
Less than once every two months [ ]
and p: £_ _ _. _ _
Inhalers
Only got it once
Once a week
[ ]
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
you pay per month in £
Less than once every two months [ ]
and p: £_ _ _. _ _
Tablets/
lozenges
Only got it once
Once a week
[ ]
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
you pay per month in £
Less than once every two months [ ]
and p: £_ _ _. _ _
Spray
Only got it once
Once a week
[ ]
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
you pay per month in £
Less than once every two months [ ]
and p: £_ _ _. _ _
Electronic
cigarettes
known as
e-cigarettes
Only got it once
Once a week
[ ]
[ ]
Once every two weeks
[ ]
Once a month
[ ]
Free on the NHS
Yes [ ]
No
[
]
If no, average amount
Once every two months [ ]
Page 9 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
8.
Patient Identification Number
Less than once every two months [ ]
you pay per month in £
Only got it once
and p: £_ _ _. _ _
[ ]
Have you accessed alcohol services in the last 6 months? (Please tick)
Yes
1 [
]
No (if no please go to question 10)
0 [
]
Not Applicable (please go to question 10)
2 [
]
9.
Which of the following alcohol services have you received? (Please tick as many that apply
to you). Please specify the total number of contacts (in the last 6 months) in the box provided.
One-to-one meetings
0 [
]
Group meetings
1 [
]
Alcohol rehabilitation services
2 [
]
Cognitive behavioural therapy (CBT)
3 [
]
Family therapy
4 [
]
Other, please give details…………………………………………………………..
5 [
]
10. Have you accessed weight management services in the last 6 months? (Please tick)
Yes
1 [
]
No (if no please go to question 12)
0 [
]
Not Applicable (please go to question 12)
2 [
]
11.
Which of the following weight management services have you received? (Please tick as
many that apply to you). Please specify the total number of contacts (in the last 6 months) in the
box provided.
One-to-one meetings with a trained advisor
0 [
]
Group meetings with a trained advisor
1 [
]
Slimming world and their food optimising plan
2 [
]
Page 10 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Weight watchers
3 [
]
Dietician
4 [
]
Other, please give details…………………………………………………………..
5 [
]
11b. Was this free on the NHS or did you, your family or carer pay for this (out of pocket)?
Free on the NHS
1 [
]
Paid for out of pocket
0 [
]
12. Have you accessed diabetes management services in the last 6 months? (Please tick)
Yes
1 [
]
No (if no please go to Section B)
0 [
]
Not Applicable (please go to Section B)
2 [
]
13.
Which of the following diabetes management services have you received? (Please tick as
many that apply to you). Please specify the total number of contacts (in the last 6 months) in the
box provided.
One-to-one meetings with a trained advisor
0 [
]
Group meetings with a trained advisor (eg Diabetes UK voluntary groups)
1 [
]
Newsletters
2 [
]
Diabetes UK Careline
3 [
]
Online communities and forums (eg www.diabetessupport.co.uk)
4 [
]
Diabetes UK tracker application (app) on your phone
5 [
]
Eye tests for diabetic retinopathy
6 [
]
Other, please give details…………………………………………………………..
7 [
]
Page 11 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
SECTION B: OTHER DAYTIME ACTIVITIES
Please complete below for all of the types of activities and daytime services that you have used in
the last 6 months. Leave blank if you have not participated in that activity or used that type of
service
Service
Name of service
Who runs the service?
1
2
3
4
5
6
NHS
Local authority
Voluntary
organisation
Private
Community group
Other, please give
details
How many
months have
you been using
the service?
In the average
week, how many
hours do you use
the service?
Leisure centre or gym
Sports club or other leisure
activities
(e.g. football, netball, tennis,
horse-riding) please specify
Day centre
Voluntary work
Adult education
Drop-in centre
Social club
One-to-one activities
(e.g. Goldhurst: please give
details)
Other service (please give
details)
Page 12 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 2: International Physical Activity Questionnaire (IPAQ)
The questions are about the time you spent being physically active in the last 7 days. They
include questions about activities you do at work, as part of your house work, to get from
place to place, and in your spare time for recreation, exercise or sport.
Please answer each question even if you do not consider yourself to be an active person.
In answering the following questions,
vigorous physical activities refer to activities that take hard physical effort and make you
breathe much harder than normal.
moderate activities refer to activities that take moderate physical effort and make you
breathe somewhat harder than normal.
1a. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting,
digging, aerobics, or fast bicycling?
Think about only those physical activities that you did for at least 10 minutes at a time.
________ days per week
or
•
1b. How much time in total did you usually
spend on one of those days doing vigorous
physical activities?
_____ hours ______ minutes
None
2a. Again, think only about those physical activities that you did for at least 10 minutes at a time.
During the last 7 days, on how many days did you do moderate physical activities like carrying light
loads, bicycling at a regular pace, or doubles tennis? Do not include walking.
________ days per week
or
2b. How much time in total did you usually
spend on one of those days doing moderate
physical activities?
_____ hours ______ minutes
None
Page 13 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
3a. During the last 7 days, on how many days did you walk for at least 10 minutes at a time? This
includes walking at work and at home, walking to travel from place to place, and any other walking
that you did solely for recreation, sport, exercise or leisure.
________ days per week
or
3b. How much time in total did you usually
spend walking on one of those days?
_____ hours ______ minutes
•
None
The last question is about the time you spent sitting on weekdays while at work, at home, while
doing course work and during leisure time. This includes time spent sitting at a desk, visiting
friends, reading, travelling on a bus or sitting or lying down to watch television.
4. During the last 7 days, how much time in total did you usually spend sitting on a week day?
____ hours ______ minutes
Page 14 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 3: EQ-5D-5L Health Questionnaire
Under each heading, please tick the ONE box that best describes your health TODAY
MOBILITY
I have no problems in walking about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about
SELF-CARE
I have no problems washing or dressing myself
I have slight problems washing or dressing myself
I have moderate problems washing or dressing myself
I have severe problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework,
family or leisure activities)
I have no problems doing my usual activities
I have slight problems doing my usual activities
I have moderate problems doing my usual activities
I have severe problems doing my usual activities
I am unable to do my usual activities
Page 15 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
PAIN / DISCOMFORT
I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
I have extreme pain or discomfort
ANXIETY / DEPRESSION
I am not anxious or depressed
I am slightly anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed
Page 16 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
The best health

We would like to know how good or bad your health is
you can imagine
100
TODAY.

This scale is numbered from 0 to 100.
95

100 means the best health you can
90
imagine.
85
0 means the worst health you can
80
imagine.


75
Mark an X on the scale to indicate how
your health is TODAY.
70
Now, please write the number you
65
marked on the scale in the box below.
60
55
50
45
40
YOUR HEALTH TODAY =
35
30
25
20
15
10
5
0
The worst health
you can imagine
Page 17 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 4: Medical Outcomes Study: Social Support Survey – (MOS-SSS)
About how many close friends and close relatives do you have (people you feel at ease with
and can talk to about what is on your mind)?
Write in number of close friends and close relatives:
People sometimes look to others for companionship, assistance or other types of support.
How often is each of the following kinds of support available to you if you need it? Please
tick the appropriate box for each statement
None
of the
time
A little
of the
time
Some
of the
time
Most of
All of the
the
time
time
Someone you can count on to listen
when you need to talk
Someone to give you information to help
you understand a situation
Someone to give you good advice about
a crisis
Someone to confide in or talk to about
yourself or your problems
Someone whose advice you really want
Someone to share your most private
worries and fears with
Someone to turn to for suggestions
about how to deal with a personal
problem
Someone who understands your
problems
Someone to help you if you were
confined to bed
Someone to take you to the doctor if you
needed it
Someone to prepare your meals if you
were unable to do it yourself
Someone to help with daily chores if you
were sick
Someone who shows you love and
affection
Page 18 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
None
of the
time
A little
of the
time
Some
of the
time
Most of
All of the
the
time
time
Someone to love and make you feel
wanted
Someone who hugs you
Someone to have a good time with
Someone to get together with for
relaxation
Someone to do something enjoyable
with
Someone to do things with to help you
get your mind off things
This section asks you questions on who you would go to for different kinds of support. Please tick
the box next to each person you would go to for support. If you would go to a family member
please say who this person is (for example son, mother, sister)
Would you go to any of the following people to talk about problems?
Friend
Partner or spouse
Support worker
Mental health key worker
Family member
please give details……………….……………………………….
Other person
please give details……………….………………………………..
Nobody
Page 19 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Would you ask any of the following people to go to an important appointment with you?
Friend
Spouse or partner
Support worker
Mental health key worker
Family member
please give details……………….……………………………….
Other person
please give details……………….……………………………….
Nobody
Would you go to any of the following people to do something fun with?
Friend
Spouse or partner
Support worker
Mental health key worker
Family member
please give details……………….……………………………….
Other person
please give details……………….……………………………….
Nobody
Would you go to any of the following people to feel love or affection?
Friend
Spouse or partner
Support worker
Mental health key worker
Family member
please give details……………….……………………………….
Other person
please give details……………….……………………………….
Nobody
Page 20 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 5: Scale to Assess Therapeutic Relationships in Community Mental
Health Care (STAR)
If you have a mental health key worker please complete this questionnaire. If you do not have a
mental health key worker please go to Patient Questionnaire 5.
Please tick the box that best describes your relationship with your mental health key
worker
Never
Rarely
Some
times
Often
Always
My mental health worker speaks with me
about my personal goals and thoughts
about treatment
My mental health worker and I are open
with one another
My mental health worker and I share a
trusting relationship
I believe my mental health worker
withholds the truth from me
My mental health worker and I share an
honest relationship
My mental health worker and I work
towards mutually agreed upon goals
My mental health worker is stern with
me when I speak about things that are
important to me and my situation
My mental health worker and I have
established an understanding of the kind
of changes that would be good for me
My mental health worker is impatient
with me
My mental health worker seems to like
me regardless of what I do or say
We agree on what is important for me to
work on
I believe my mental health worker has an
understanding of what my experiences
have meant to me
Page 21 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 6: Morisky Scale of Adherence (MMS): Psychiatric Medications
Please answer the following questions based on your personal experiences of taking
ANTIPSYCHOTIC MEDICATION, ANTIDEPRESSANT MEDICATION, MOOD STABILISERS or any
other medication for your mental health
YES
NO
Do you sometimes forget to take your psychiatric medication?
People sometimes miss taking their medicines for reasons other
than forgetting. Thinking over the past 2 weeks, were there any
days when you did not take your psychiatric medication?
Have you ever cut back or stopped taking your medications
without telling your doctor because you felt worse when you took
it?
When you travel or leave home, do you sometimes forget to bring
along your psychiatric medication?
Did you take your psychiatric medication yesterday?
When you feel like your psychiatric symptoms are under control,
do you sometimes stop taking your medicine?
Taking medicine every day is a real inconvenience for some
people. Do you ever feel hassled about sticking to your treatment
plan?
Never/ Once in
Rarely a while
Some
times
Usually
All the
time
How often do you have difficulty
remembering to take all your psychiatric
medications?
Page 22 of 24
NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
Patient Questionnaire 7: Morisky Scale of Adherence (MMS) - CVD preventative
medications
Please answer the following questions based on your personal experiences of taking
STATINS, ANTIHYPERTENSIVES, METFORMIN, STOP-SMOKING MEDICATION and/or
DIABETIC medications
YES
NO
Do you sometimes forget to take your medications?
People sometimes miss taking their medicines for reasons other
than forgetting. Thinking over the past 2 weeks, were there any
days when you did not take your medications?
Have you ever cut back or stopped taking your medications
without telling your doctor because you felt worse when you took
it?
When you travel or leave home, do you sometimes forget to bring
along your medication?
Did you take your medications yesterday?
When you feel like your symptoms are under control, do you
sometimes stop taking your medication?
Taking medicine every day is a real inconvenience for some
people. Do you ever feel hassled about sticking to your treatment
plan?
Never/ Once in
Rarely a while
Some
times
Usually
All the
time
How often do you have difficulty
remembering to take all your
medications?
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NIHR PROJECT: RP-PG-0609-10156
The PRIMROSE Study
6 month follow up PQ/VN4: 20/10/2014
Patient Identification Number
End of
Questionnaires
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NIHR PROJECT: RP-PG-0609-10156