Questionnaire for Self-Assessment of the Social Significance of Illness Test - the question form
Questions: 10 · 2 minutes
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Male form
Female form
1. Because of my illness, I cannot work as effectively as before; I have become weak and frail, and I find myself unpleasant.
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
2. My illness complicates relationships in my family; I feel that I have become a burden to my relatives.
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
3. Because of my illness, I have to restrict myself in many ways (e.g., I am afraid to drink alcohol, I limit my food intake, I avoid visiting others, I deny myself entertainment).
Definitely no
Probably no
Not sure
Probably yes
Definitely yes
4. Because of my illness, my relationships at work have worsened; I feel that coworkers treat me worse, show no sympathy, and even pick on me.
Definitely not
Probably not
Not sure
Probably yes
Definitely yes
5. I feel that I have less free time than healthy people because my illness takes up a lot of time (treatment, hospital visits, etc.).
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
6. Because of my illness, I cannot work where I want. My illness prevents me from improving my social standing or advancing my career.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
7. Since becoming ill, I have noticed changes in my appearance; I feel unattractive and unpleasant to others.
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
8. My illness has made me unhappy and has made me feel different from others.
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
9. My illness interferes with my social interactions; I feel that I am distancing myself from other people.
1 – Definitely not
2 – Probably not
3 – Not sure
4 – Probably yes
5 – Definitely yes
10. My illness causes me significant financial loss, makes me spend money on treatment, and prevents me from earning more.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
1. Because of my illness, I cannot work as effectively as before; I have become weak and frail and feel unpleasant to myself.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
2. My illness complicates relationships in my family; I feel that I have become a burden to my loved ones.
1 – Definitely not
2 – Probably not
3 – Hard to say
4 – Probably yes
5 – Definitely yes
3. Because of my illness, I have to limit myself in many ways (for example, I am afraid to drink alcohol, I restrict my diet, avoid visiting others, and give up entertainment).
Definitely not
Probably not
Not sure
Probably yes
Definitely yes
4. Because of my illness, my relationships at work have worsened; I feel that my colleagues treat me worse, do not sympathize, and even pick on me.
1 – Definitely not
2 – Probably not
3 – Hard to say
4 – Probably yes
5 – Definitely yes
5. I feel that I have less free time than healthy people because my illness takes up a lot of time for treatment, hospital visits, etc.
1 – Definitely not
2 – Probably not
3 – Difficult to answer
4 – Probably yes
5 – Definitely yes
6. Because of my illness, I cannot work where I want. My illness prevents me from achieving a better position in society or advancing my career.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
7. Since becoming ill, I have noticed changes in my appearance; I feel unattractive and unpleasant to others.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
8. My illness has made me unhappy and makes me feel different from others.
1 - Definitely not
2 - Probably not
3 - Hard to say
4 - Probably yes
5 - Definitely yes
9. My illness interferes with my communication with others; I feel that I am becoming distant from people.
1 – Definitely no
2 – Probably no
3 – Not sure
4 – Probably yes
5 – Definitely yes
10. My illness causes me significant financial loss, makes me spend money on treatment, and prevents me from earning more.
1 – Definitely no
2 – Probably no
3 – Difficult to answer
4 – Probably yes
5 – Definitely yes