Table 1. End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ).

This survey asks for your opinion about how well you follow your dialysis treatment schedule and about medical recommendations related to medication, diet, and fluid intake. This information will help us to understand if you have difficulty following your dialysis treatment, medication regimen, fluid restriction, and recommended diet. Please answer every question by marking the appropriate box. If you are unsure about how to answer, please choose one best answer that applies to you.

Note: Numbers in parentheses are the response codes.

I. General Information
1.	When did you begin or restart your hemodialysis treatment?	Beginning Date:
		(Restarting date if you restarted hemodialysis: )
2.	Have you ever had chronic peritoneal dialysis treatment?	No(1)
		Yes(2) (Please answer below)
		I had peritoneal dialysis from
3.	Have you had a kidney transplant?	No(1)
		Yes(2) (Please answer below)
		I had a kidney transplant once from
		Or
		I had kidney transplants twice from and from
		If you have had transplants more than twice, please write the dates in the spaces above for the last two transplants.
4.	What type of transportation do you use to go to the dialysis center?	□	Personal transportation(1)
		□	Bus(2)
		□	Taxi(3)
		□	Medical transportation van(4)
		□	Other (Specify)(5): ____________
5.	Who accompanies you to the dialysis center?	□	Myself(1)
		□	Parent(2)
		□	Spouse (Husband or wife)(3)
		□	Child(4)
		□	Friend(5)
		□	Other (Specify the person)(6): ____________
II. Hemodialysis Treatment
6.	How many days a week do you receive hemodialysis treatment?	□	2 days or less(1)
		□	3 days(2)
		□	4 days(3)
		□	More than 4 days(4)
		□	More than 5 days(5)
7.	How many hours are you treated for each hemodialysis?	□	Less than 3 hours(1)
		□	3 hours(2)
		□	3 hours and 15 minutes(3)
		□	3 hours and 30 minutes(4)
		□	3 hours and 45 minutes(5)
		□	4 hours(6)
		□	More than 4 hours(7)
		□	Other (Specify the hours)(8): ____________
8.	Is your dialysis schedule convenient for you? (Please choose one best answer that applies to you.)	□	Yes(1)
		□	No, because I have to come to the dialysis center too early(2)
		□	No, because I have to come to the dialysis center too late(3)
		□	No, because of my work schedule(4)
		□	No, because it is my meal time and I get hungry during dialysis treatment(5)
		□	No, because it is my medication time and I have to take medicines/insulin(6)
		□	No, because of (Other)(7): ____________
9.	When was the last time a medical professional (your doctor, nurse, dietician, or other medical staff) talked to you about the importance of not missing your dialysis treatment?	□	This week(1)
		□	Last week(2)
		□	One month ago(3)
		□	More than a month ago(4)
		□	When I first began dialysis treatment(5)
		□	Never(6)
		□	Other (Specify)(7): ___________
10.	How often does a medical professional (your doctor, nurse, dietician, or other medical staff) talk to you about the importance of staying for the entire dialysis time during your dialysis treatment?	□	Every dialysis treatment(1)
		□	Every week(2)
		□	Every month(3)
		□	Every 2 to 3 months(4)
		□	Every 4 to 6 months(5)
		□	When I have abnormal blood or other test results(6)
		□	Rarely(7)
		□	Irregularly(8)
		□	Never(9)
		□	Other (Specify)(10): ___________
11.	How important do you think it is to follow your dialysis schedule?	□	Highly important(1)
		□	Very important(2)
		□	Moderately important(3)
		□	A little important(4)
		□	Not important(5)
12.	Why do you think it is important to follow your dialysis schedule? (Please choose one best answer that applies to you.)	□	Because I fully understand that my kidney condition requires dialysis as scheduled(1)
		□	Because following the dialysis schedule is important to keep my body healthy(2)
		□	Because medical professional (my doctor, nurse, or dietitian) told me to do so(3)
		□	Because I had an experience that I was sick after I missed dialysis(4)
		□	Because I had an experience that I was hospitalized after I missed dialysis(5)
		□	I don't think following the dialysis schedule is very important to me(6)
		□	Other (Specify)(7): ____________
13.	How much difficulty have you had staying for your entire dialysis treatment as ordered by your doctor?	□	No difficulty(1)
		□	A little difficulty(2)
		□	Moderate difficulty(3)
		□	A lot of difficulty(4)
		□	Extreme difficulty(5)
14.	During the last month, how many dialysis treatments did you miss completely?	□	None (I did not miss any treatments)(1)
		□	Missed one dialysis treatment(2)
		□	Missed two dialysis treatments(3)
		□	Missed three dialysis treatments(4)
		□	Missed four or more dialysis treatments(5)
15.	What was the main reason you missed your dialysis treatment last month?	□	Not applicable: I did not miss any treatment(1)
		□	Transportation problems(2)
		□	I had other things to do (Please explain)(3):
		□	Hemodialysis access (graft, fistula, or catheter) clotted(4)
		□	Physician (medical or surgical) appointment(5)
		□	I had to go to the emergency room(6)
		□	I was hospitalized(7)
		□	Forgot(8)
		□	“Didn't want to go” or “Couldn't go” (Go to the next question: Question #16)(9)
		□	Other (Please specify)(10): ____________
16.	(Answer this question when you marked the above question as “Didn't want to go Couldn't go.”) Why didn't you want to go to the dialysis center? (Please choose one best answer that applies to you)	□	Because dialysis treatment makes me anxious(1)
		□	Because I had vomiting/diarrhea(2)
		□	Because I had cramping(3)
		□	Because I often get hungry during dialysis treatment(4)
		□	Because I was physically uncomfortable (Specify the condition)(5)
		□	Because I was sick due to other conditions (Specify the conditions)(6)
		□	Because I was emotionally depressed(7)
		□	Other(8): ____________
17.	During the last month, how many times have you shortened your dialysis time?	□	Not applicable: I have not shortened my dialysis time(1)
		□	Once(2)
		□	Twice(3)
		□	Three times(4)
		□	Four to five times(5)
		□	Other (Specify frequency)(6): ____________
18.	During the last month, when your dialysis treatment was shortened, what was the average number of minutes?	□	Not applicable: I have not shortened my dialysis time(1)
		□	Less than 10 minutes or 10 minutes(2)
		□	11 to 20 minutes(3)
		□	21 to 30 minutes(4)
		□	More than 31 minutes(5)
		□	Other (Specify)(6) (If you need to write two or more different time because you shortened dialysis more than once, please use this space): _____________________________
19.	What was the main reason you have shortened your dialysis treatment?	□	Not applicable: I have not shortened my dialysis time(1)
		□	Cramping(2)
		□	Bathroom use(3)
		□	Restlessness(4)
		□	Low blood pressure(5)
		□	Access (graft, fistula, or catheter) clotted(6)
		□	Physician (medical or surgical) appointment(7)
		□	Personal business or emergency(8)
		□	Work schedule(9)
		□	Transportation problems(10)
		□	Staff decision (Why? Please explain: For example, poor blood flow, clotting dialyzer, machine malfunction, etc.)(11): ____________
		□	Did not feel like staying(12)
		□	Other (Please specify)(13): ____________
III. Medication
20.	When was the last time a medical professional (your doctor, nurse, dietician or other medical staff) spoke to you about your medicines?	□	This week(1)
		□	Last week(2)
		□	One month ago(3)
		□	More than a month ago(4)
		□	When I first began dialysis treatment(5)
		□	Never(6)
		□	Other (Specify)(7): ____________
21.	How often does a medical professional (your doctor, nurse, dietician or other medical staff) talk to you about the importance of taking medicines as ordered?	□	Every dialysis treatment(1)
		□	Every week(2)
		□	Every month(3)
		□	Every 2 to 3 months(4)
		□	Every 4 to 6 months(5)
		□	When I have abnormal blood or other (for example, blood pressure) test results(6)
		□	Rarely(7)
		□	Irregularly(8)
		□	Never(9)
		□	Other (Specify)(10): ____________
22.	How important do you think it is to take your medicines as scheduled?	□	Highly important(1)
		□	Very important(2)
		□	Moderately important(3)
		□	A little important(4)
		□	Not important(5)
23.	Why do you think it is important to take your medicines as scheduled? (Please choose one best answer that applies to you.)	□	Because I fully understand that my kidney condition requires to take medicines as scheduled(1)
		□	Because taking medicines is important to keep my body healthy(2)
		□	Because a medical professional (my doctor, nurse, dietician, or other medical staff) told me to do so(3)
		□	Because I had an experience that I was sick after I missed medicines(4)
		□	Because I had an experience that I was hospitalized after I missed medicines(5)
		□	I don't think taking medicines is very important to me(6)
		□	Other (Specify)(7): ____________
24.	Have you had any difficulty with taking your medicines?	□	No(1)
		□	Yes(2)
25.	How much difficulty have you had with taking your prescribed medicines?	□	No difficulty(1)
		□	A little difficulty(2)
		□	Moderate difficulty(3)
		□	A lot of difficulty(4)
		□	Extreme difficulty(5)
26.	During the past week, how often have you missed your prescribed medicines?	□	None of the time: I did not miss my medicines(1)
		□	Very seldom(2)
		□	About half of the time(3)
		□	Most of the time(4)
		□	All of the time(5)
27.	What was the main reason for not taking your prescribed medicines this past week?	□	Not applicable: I did not miss medicines(1)
		□	Forgot to take medicines(2)
		□	Forgot to order medicines(3)
		□	Medicine cost(4)
		□	Inconvenience(5)
		□	I was hospitalized(6)
		□	Side effects(7) (Go to question #28)
		□	Other(8): _____________
28.	(Answer this question when you have marked the above question as “Side effects.”) What kind of side effect(s) to the medication(s) did you have? (Please choose one best answer that applies to you.)	□	Loss of appetite(1)
		□	Nausea/vomiting/diarrhea/constipation(2)
		□	Stomach pain(3)
		□	Dizziness(4)
		□	Headache(5)
		□	Itching/skin problems(6)
		□	Other (Specify symptoms)(7): _____________
IV. Fluid
29.	When was the last time a medical professional (your doctor, nurse or dietician or other medical staff) spoke to you about your fluid restrictions?	□	This week(1)
		□	Last week(2)
		□	One month ago(3)
		□	More than a month ago(4)
		□	When I began dialysis treatment(5)
		□	Never(6)
		□	Other (Specify)(7): _____________
30.	How often does a medical professional (your doctor, nurse, dietician or other medical staff) talk to you about the importance of fluid restriction?	□	Every dialysis treatment(1)
		□	Every week(2)
		□	Every month(3)
		□	Every 2 to 3 months(4)
		□	Every 4 to 6 months(5)
		□	When I have abnormal blood or other (for example, blood pressure) test results(6)
		□	Rarely(7)
		□	Irregularly(8)
		□	Never(9)
		□	Other (Specify)(10): _____________
31.	During the past week, how often have you followed the fluid restriction recommendations?	□	All of the time(1)
		□	Most of the time(2)
		□	About half of the time(3)
		□	Very seldom(4)
		□	None of the time(5)
32.	How important do you think it is to limit your fluid intake?	□	Highly important(1)
		□	Very important(2)
		□	Moderately important(3)
		□	A little important(4)
		□	Not important(5)
33.	Why do you think it is important for you to limit your fluid intake? (Please choose one best answer that applies to you.)	□	Because I fully understand that my kidney condition requires limiting fluid intake(1)
		□	Because limiting fluid intake is important to keep my body healthy(2)
		□	Because a medical professional (my doctor, nurse, dietician, or other medical staff) told me to do so(3)
		□	Because I got sick after I drank lots of fluid(4)
		□	Because I was hospitalized after I drank lots of fluid(5)
		□	I don't think limiting fluid is very important to me(6)
		□	Other (Specify)(7): _____________
34.	Have you had any difficulty with limiting your fluid intake?	□	No(1)
		□	Yes(2)
35.	How much difficulty have you had following your fluid restriction recommendations?	□	No difficulty(1)
		□	A little difficulty(2)
		□	Moderate difficulty(3)
		□	A lot of difficulty(4)
		□	I was unable to follow any recommendations at all(5)
36.	If you had difficulty following your fluid restriction recommendations, what type of difficulty have you had?	□	No difficulty(1)
		□	Not interested(2)
		□	I was unable to control fluid intake(3)
		□	I don't understand how to follow the fluid restriction(4)
		□	Other(5): ____________
37.	During the past week, how many times have you weighed yourself at home (outside dialysis center)?	□	More than 3 times(1)
		□	3 times(2)
		□	Twice(3)
		□	Once(4)
		□	None of the time(5)
		□	Other(6): ____________
38.	How important do you think it is to weigh yourself daily?	□	Highly important(1)
		□	Very important(2)
		□	Moderately important(3)
		□	A little important(4)
		□	Not important(5)
V. Diet
39.	When was last time a medical professional (your doctor, nurse, dietician, or other medical staff) talked to you about your diet?	□	This week(1)
		□	Last week(2)
		□	One month ago(3)
		□	More than a month ago(4)
		□	When I first began dialysis treatment(5)
		□	Never(6)
		□	Other (Specify)(7): ____________
40.	How often does a medical professional (your doctor, nurse, dietician or other medical staff) talk to you about the importance of following a proper diet?	□	Every dialysis treatment(1)
		□	Every week(2)
		□	Every month(3)
		□	Every 2 to 3 months(4)
		□	Every 4 to 6 months(5)
		□	When I have abnormal blood or other (for example, blood pressure) test results(6)
		□	Rarely(7)
		□	Irregularly(8)
		□	Never(9)
		□	Other (Specify)(10): ____________
41.	How important do you think it is to watch the types of food you eat each day?	□	Highly important(1)
		□	Very important(2)
		□	Moderately important(3)
		□	A little important(4)
		□	Not important(5)
42.	Why do you think it is important for you to watch your diet daily? (Please choose one best answer that applies to you.)	□	Because I fully understand that my kidney condition requires to watch my diet(1)
		□	Because watching my diet is important to keep my body healthy(2)
		□	Because a medical professional (my doctor, nurse, or dietician) told me to do so(3)
		□	Because I got sick after eating certain food that I was not supposed to eat(4)
		□	Because I was hospitalized after eating certain food that I was not supposed to eat(5)
		□	I don't think watching my diet is important to me(6)
		□	Other (Specify)(7): ____________
43.	Have you had any difficulty following your dietary recommendations?	□	No(1)
		□	Yes(2)
44.	How much difficulty have you had following your dietary recommendations?	□	No difficulty(1)
		□	A little difficulty(2)
		□	Moderate difficulty(3)
		□	A lot of difficulty(4)
		□	I was unable to follow any recommendations at all(5)
45.	What type of difficulty have you had keeping your dietary recommendations?	□	Not applicable: No difficulty(1)
		□	I was not willing to control what I want to eat(2)
		□	I was unable to avoid certain unrecommended food(3)
		□	I don't understand what type of diet to follow(4)
		□	Other (Specify)(5): ____________
46.	During the past week, how many times have you followed the diet recommendations?	□	All of the time(1)
		□	Most of the time(2)
		□	About half of the time(3)
		□	Very seldom(4)
		□	None of the time(5)