Health And Social Questionnaire
Health and social questionnaires are used to understand the social well being of households in a particular region, area, or city. The questionnaires can contain information varying from general health condition to specific medical conditions, work related illness, child health, pregnancy and breastfeeding, education, employment, and physical measurements among others. This type of questionnaire is filled by every member of a household.
Health And Social Questionnaire Sample
Name of the individual: _______________________________________
Sex: _______ Age: _________ Marital Status: ____________________
Role in the Household: ________________________________________
Relationship with head of household: _____________________________
Occupation: ____________________ College/School: _______________
Type of accommodation: (Rented/Rent free/Owned): ________________
Address: ___________________________________________________
City: ________________ State: ______________ Zip: ______________
Telephone: ____________________ Fax: ________________________
Q1. How would you score your general health?
a) Excellent
b) Very Good
c) Good
d) Average
e) Bad
f) Poor
Q2. In the last 12 months how often have you visited a doctor for treatment of medical ailment?
a) Once
b) 1-5 times
c) 5-10 times
d) More than 10 times
Q3. Do you have any long standing disability or illness? If yes, please specify
a) Yes
b) No
c) Illness/Disability:_____________________________
Q4. Have you faced any pregnancy complications?
a) Yes
b) No
Q5. Which of these do you follow or use on a regular basis?
a) Healthy diet
b) Exercise
c) Aerobics
d) Herbal medicine
e) Adventure sports
Q6. Do you have any of the following habits?
a) Smoking
b) Drinking Alcohol
c) Caffeine
d) Sleeping medicines
Q7. Please provide information on the following:
Height:_________ Weight: _________
Waist: __________ Chest: __________
Q8. Are you religious?
a) Yes
b) No
Q9. How often do you visit a place of worship?
a) Every day
b) Once a week
c) Only on weekends
d) Once in a fortnight
e) Once in a month
f) Never
Q10. What is your income per month or annually?
________________________________________________________
Category: Social Questionnaire