CAPITOL UNIVERSITY

College of Nursing

NURSING ASSESSMENT: QUESTIONNAIRE AND DATA SHEET

Please answer the following questions as honestly as you can, put a check on the
appropriate boxes that correspond to your answer.

A. BIOLOGICAL, DEMOGRAPHIC AND SOCIO-CULTURAL FACTORS

Age: _______________ Sex:  Female  Male

Ethnic Background: ________________________ Religion: _______________

1. Do you participate in the company’s activities? (ex. “HATAW” activities etc.)

 Yes  No
2. Do you avail of the company’s health privileges? (Ex. company clinics)
 Yes  No

B. ENVIRONMENTAL FACTORS

Please put a check () on the appropriate boxes that correspond to your answer.

How do you rate the following factors regarding their contribution towards good health?

A. WORKING FACILITIES:

 Very good  Good  Moderate  Not Healthy

B. SAFETY TOWARDS ACCIDENT HAZARDS:

 Very good  Good  Moderate  Not Safe

C. SOURCES OF FOOD: (canteen)

 Very good  Good  Moderate  Not Healthy

D. WATER SUPPLY:

 Very good  Good  Moderate  Not Healthy

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 E. TOILET FACILITY:

 Very good  Good  Moderate  Not Healthy

F. GARBAGE AND REFUSE DISPOSAL:

 Very good  Good  Moderate  Not Healthy

G. DRAINAGE SYSTEMS:

 Very good  Good  Moderate  Not Healthy

H. SOCIAL AND HEALTH FACILITIES:

 Very good  Good  Moderate  Not Healthy

I. SOCIAL AND HEALTH PROGRAMS:

 Very good  Good  Moderate  Not Healthy

J. COMPANY’S SAFETY PROGRAMS/ DRILLS:

 Very good  Good  Moderate  Not Healthy

K. RULES AND POLICIES FOR SAFETY:

 Very good  Good  Moderate  Not Healthy

L. COMPANY’S OF COMMUNICATION AND TRANSPORTATION SYSTEM:

 Very good  Good  Moderate  Not Healthy

C. HEALTH AND MEDICAL HISTORY:

1. Do you have histories of any work related past hospitalizations/illness?

 Yes  No

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2. Do you have any history of any hereditary diseases (self and family members)?
 Yes  No
If YES, please check appropriate box/es below:

 Hypertension (High Blood Pressure)

 Diabetes Mellitus
 Heart Diseases
 Cancer
Other: ______________________________________________

3. How do you value health?

 I value health very much

 I value health moderately
 I do not value health that much
 I never valued health

4. Do you have any complaints regarding your current health condition?

 Yes  No

If yes, what are those complaints?

 Low Back Pain
 Cough and Colds
 Eye Problems
 Sleep Problems
 Stressed
 Fever
Other: ______________________________________________

Thank you for your cooperation…

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