48 Exploring the difference made by Support at home appendix d Pre- and post-service questionnaires Date & time of interview BRC number Postcode Name of interviewer prE- service Questionnaire Remember to gain consent! Please reassure the service user that it is their views and experiences that are important to us. There are no right or wrong answers! i would like you to think about your daily life, carrying out your day to day activities. I’m going to ask you some general questions, could you indicate for me using the scoring system on this card how confident you currently are that you can do certain things (SHOW CARD 1). One means you feel you cannot do it at all, 5 means you feel certain that you can do it. And the middle of the scale is 3. Thinking about your daily activities, cannot certain Depends/ how able are you to do the do at all can do DK/NA/ following: Refuse 1 2 3 4 5 Write in 1. To look after yourself, for 1 2 3 4 5 example, to wash, get dressed... Comments 2. To do daily tasks around the home, for example tidying, 1 2 3 4 5 cleaning… Comments 3. To get out & about, for example, 1 2 3 4 5 go shopping, do your errands… Comments 4. Do you have someone to help Yes / Sometimes / No / DK you do any of these things? If so, Who? Circle all that apply 1. Family 2. Friends 3. Neighbours 4. Homecare 5. Other Please specify: 5. Can I just check who you live with? If already mentioned, write in… 6. Are you currently taking any Yes / No / DK (if No → Q8) medication? and how able are you to... cannot certain Depends/ do at all can do DK/NA/ Refuse 7. To take your medication when 1 2 3 4 5 you need to