Questionnaire for Primary Health Care Model

PERSONAL DETAILS:
1. Name of the house hold head?
2. What is your Profession?
3. What is your age?
4. What is your Gender? (M/F)
5. What is your weight and height?
6. Where do you live (address)?
7. What is your Family Monthly Income?
a) Below 5,000

b) 5,000 10,000

c) 10,000 15,000

d) above 15,000

8. How many members in your family are earning?

Fill the following information (For self and dependents):
S.no
.

Name of the Family

Memmber

Relationship Marital
with the
Status
head

Age/
Gender

Whether
employed
?

EDUCATIONAL QUALIFICATION:
9. Last class attended/ Attending?
10. What is / was your main reason to join the school?
a) Meals

b) Financial Aid

c) Education

CURRENT PERSONAL HEALTH CONDITION:

Adhaar No if any

11. How would you evaluate your overall health? Would you say you are:
a) Good

b) Mild

c) Moderate

d) Severely Ill

e) Chronic

12. Do you have any genetic Problem, If yes what is it?

a) B.P

b) Diabetes

c) Thalesemia d) Psychiatric Disorders

e) Others

13. When was the last time you got a health checkup?
a) Past two weeks

b) Before a month

c) Before 2 months

d) before 6 months

c) Water Tankers

d) Others

14. What type of food items you consume?

a)
b)
c)
d)

Potato Items
Rice and potato
Rice, Pulses and vegetables
Chapati and vegetables

e) Chapati, Vegetables and Alcohol

15. What is the source of drinking water?
a) Municipal Taps

b) Storage tanks

16. What kind of problems you usually face and how frequently?
a) Fever

b) Flu

c) Cold and Cough

d) Stomache Ache

e) Muscular Pains

f) Headache

g) Skin Problems

h) Breathing Problems

17. Are you suffering from any of the Chronic Conditions?

a) Arthritis

b) Cancer

c) Chronic Pain

d)Depression

e) Diabetes

f) Heart Disease

g) High BP

h) Asthma

18. How much do you spend monthly on your health related issues?
a) Below 1,000

b) 1,000 2,000

c) 2,000 3,000

d) 3,000 or above

19. How much are you willing to contribute on your health per day?
a) 1

b) 2

c) 3

d) 5

20. How frequently you visit a hospital?

a) Once a week

b) Twice a week

c)Monthly

d) None of the above

21. Which type of a hospital would you prefer

a) Government

b) Private

22. Are you well aware of all the vaccinations and any health problems that may occur?
a) Yes

b) Yes but not all

23. Are your children fully immunized?

a) Yes
b) No
24. What is the birth control options used?
a) Contraceptory Pills b) Condoms
25. Do you smoke?
a) Yes
b) No
26. Are you Anaemic?
a) Yes
b) No
27. Do you take medicines for BP?
a) Yes
b) No

c) No

c) Sterilisation

d) tubectomy

d) None of them

HOSPITALS/ CLINIC FACILITIES:

28. Overall, how would you rate the local hospitals in your area?
a) Excellent

b) Good

c) Fair

d) Poor

e) Not sure
29. Does the hospital you regularly visit have equipment for modern diagnosis and treatment?
c) Yes

b) No

c) Not sure

30. How much time does it take to reach to the nearest hospital/clinic?
a) 5-10 mins

b) 10-20 mins

c) 20mins-1hour

d) More than 1 hour

31. Do you have a personal family doctor?

a) Yes

b) No

32. Access to primary health care team?

a) Yes

b) No

33. How much time do you have to wait in normal or emergency conditions?
a) 15 mins

b) 30 mins

c) 45 mins

d) 1 hr

34. In case of Illness, where do you go for treatment

a) Government/ Municipal Hospital
b) Government Dispensary
c) PHC
d) Medical store
e) NGO/ Trust Clinic/Hospital
f) Vaidya/Hakim/Homopathy
35. Why don't the family members go to a government facility in case of sickness?
a) No nearby Facility
b) Facility Timing not convenient
c) Waiting time too long
d) Poor Quality of care
e) Any other reason?
36. Do you want to avail medicines for basic problems?
a) Yes

b)No

37.
Do you have any awareness towards health insurance?
a) Yes
b) No
38. Is any member covered by health insurance or health scheme? If yes, then what type of
health insurance do you possess?
a) Government

b)Private

HOUSEHOLD / AREA CONDITIONS:

39. Do you have thermometer at home?
a) Yes

b) No

40. Do you have access to filter water?

a) Yes

b) No

41. Do you have an emergency / First-Aid kit at home?

a) Yes

b) No

42. Air Ventilation where you live is:

a) Poor

b) Normal

c) Good

d) Perfect

43. Do you have a clean society?

a) Yes
c)

b) Yes, but not completely

Not at all
44. What kind of toilet facility do members of your household usually use?
a) Public Toilets

b) Private Toilets

45. When was the last time any checkups camp was held?
a) Before one month
b) Befor two months
c) Before three months
d) Before six months
46. What type of cooking fuel do you use?
e) Electricity

b) LPG

c) Kerosene

d) Wood

e) Dung Cakes

47. Is cooking done separately or in the same room where you live?
a) Yes

b) No

48. Do the members of the household have a bank account?

a) Yes

b) No

49. Do you have a bank account?

a) Yes

b) No

50. Name of the Bank

a) Nationalised Bank

b)Private Bank

51. Do you avail any government promotional policies?

a) Central Government Health Scheme
b) Rashtriya Swasthya Bim yojana
c) Rajiv Gandhi Scheme (Sabla)
d) Pradhan Mantri Suraksha Bima Yojana
e) Others

c) Rural Bank

d) Others