A. Physiologic adaptation mode
Did your disease change the functions and perceptions listed below?
1. Sitting and lying down
2. Dressing and undressing
3. Taking a bath
4. Walking at home
5. Climbing stairs
6. Walking uphill
7. Eating
8. Personal care (shaving, make-up, brushing teeth, etc.)
9. Normal defecation habits
10. Sleep habits
B. Self-concept mode
B1. Physical self-adaptation
1. I am afraid of not being able to breathe
2. Shortness of breath creates difficulties in expressing myself
3. Shortness of breath creates difficulties both for me and my family
4. My social relationships are being impaired due to my disease
5. Coughing tires me
6. I tire much easier than earlier
7. People avoid me because of my cough
8. I feel old and ugly because of my disease
9. I feel that I am a burden to my family or people close to me
10 I feel powerless, as if I couldn’t manage anything
B2. Personal self-adaptation
1. I feel useless because of my disease
2. I don’t feel strong as I used to before
3. Problems like coughing and shortness of breath place me in a difficult situation socially
4. I often ask myself why this disease happened to me
5. The future looks uncertain and dark to me
6. I feel sad, anxious and disconnected
7. I have no hopes of getting better
8. I see this disease as a divine punishment
9. I have trouble performing my worship
C. Role-function mode
1. I cannot do the things I used to do before becoming sick
2. I have difficulties with entertainment and sport
3. I cannot perform activities like cooking, repairs, or cleaning as easily as I used to
4. I cannot take care of chores like paying bills or shopping as easily as I used to
5. The disease keeps me from doing something to earn my living
6. I have trouble caring for my children