Health Education Questionnaire

June 8, 2011

This health education questionnaire is being distributed by ABC Health Care in order to grasp the level of health awareness among different sects of the society. Here are a few simple questions for you answer:

  1. Name:
  1. Age:
  1. Address:
  1. Phone:
  1. What do u do(occupation):
  1. Please tick if you suffer from any of the following chronic disorders:

a) Diabetes     b) Asthma    c) Heart Disease    d) Lung disease

e) Cancer        f) COPD     d) other (please specify)

  1. In general, what would you say about your health:

a) Excellent     b) Very good    c) good     d) Fair    e) Poor

  1. Do you go to get your gum check regularly?
  1. Do you walk/jog or run regularly?
  1. Has your health interfered with normal social activities?
  1. Does your health interfere with normal household chores?
  1. Do you have any kind of persistent body ache?
  1. How often do you visit your general physician?
  1. How many times in the last 1 year have you been hospitalized?
  1. Do you suffer from shortness of breath?
  1. Do you get easily fatigued?
  1. Do you have any other health problems or issues you want to give in detail:

Download Sample Health Education Questionnaire in Word Format

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