OLIVAREZ COLLEGE

Dr. Arcadio Santos Avenue, Sucat Road, Parañaque City

College of Nursing

Dear Respondents,

We are the third year nursing students of Olivarez College in Paranaque City who are currently
conducting a study on “LIFESTYLE AND HABITS OF CALL CENTER AGENTS IN RELATION TO COMMON
HEALTH COMPLAINTS: CRAFTING PROMOTIONAL TOOL”. In this regard, we are asking for your full
cooperation in answering the attached survey questionnaire honestly. Your answer would be a great
help for us in this study. Rest assureds that your answers will be kept confidentially. We are looking
forward for your cooperation.

Cascon, Marie Karl A.

Duterte, Maria Denessa Ann D.

Waytan, Zelaida Ashley

Sirot, Angelica M.

Direction: This is a self- evaluation. Please answer the following questions as honestly as possible by
checking the boxes below.

Demographic Profile

Age: (What is the basis of this age group? how was this clustered and identified? might as well follow the
developmental model in relevance to health perception)
18-24 25-31 32-38 39-45 46 and above

Gender: (Use sex if male or female, because gender is different and there are lots in the category)
Male Female

Civil Status: (please also include divorced as it is the official civil status in the philippine statistics
authority)
Single Married Widowed Separated

Occupational Status

Part Time student

Part Time Employee Full Time Employee

Work Shift: (how do you differentiate night shift versus graveyard shift?) and there is also a rotating shift)
might as well have them indicate their work schedules then cluster it upon data analyses
Morning Shift Night Shift Graveyard Shift

Estimated time of travel from home to office

15 mins or less 30 mins-1 hour 1-2 hours 3-4hours

Estimated time of travel from office to home

15 mins 30 mins 1-2 hours 3-4hours
 OLIVAREZ COLLEGE
Dr. Arcadio Santos Avenue, Sucat Road, Parañaque City
College of Nursing

I Questions about your Lifestyles and Habits

Instruction: Assess your-self by answering the following statement. Put a check mark under the
corresponding column of your choice that are appropriate in your lifestyle and habits.
Please identify instances for: Always, often, sometimes, seldom and never)
Ex. Always (more than 5x, or daily)

Describe your Likert scale (Ex. Always, 5x above, or 1 ALWAYS OFTEN SOMETIMES SELDOM NE
pack of cigarettes/day) 5 4 3 2

I drink alcohol beverage. (like beer, brandy, wine, etc)

I smoke cigarette. (how many sticks_____)

I use prohibited drugs. (like shabu, weeds, cocaine,etc)

I sleep 6-8 hrs a day.

I eat regularly. (Desrcive this as: 3x a day, etc.)

I eat nutritious foods.

I eat junk foods. (like chips, burger, pizza, etc)

I drink coffee (how many cups ____ )

I exercise:

Everyday

Every week

Twice a week

I void as needed.

I defecate regularly. (There is a different bowel movement

per person) safe to use once a day, every other day etc.

I watch television. (How many hours a day)

I go shopping. (how many time in a month)

I buy latest gadgets.

I go to parties (events).

I go to clubs and bars:

Everyday
 OLIVAREZ COLLEGE
Dr. Arcadio Santos Avenue, Sucat Road, Parañaque City
College of Nursing

Every week

Every month

I bond with my family.

I go out with my friends.

I stay at home during rest day.

I work overtime.

II Questions about your Health Complaints

(For pain related questions, please also indicate the pain ALWAYS OFTEN SOMETIMES SELDOM NE
scale for the respondents’ convenience) Same also here, 5 4 3 2
please indicate and define what is the instance for
always, often etc.

Mild headache.

Moderate headache

Severe headache

Dizziness

Tired eyes

Irritated eyes

Colds

Cough

Difficulty of breathing

Toothache

Sore throat

Hoarseness of voice

Neck pain

Shoulder pain
 OLIVAREZ COLLEGE
Dr. Arcadio Santos Avenue, Sucat Road, Parañaque City
College of Nursing

Chest pain

Numbness on my hands and fingers

Feeling bloated

Stomach pain

Constipation

Diarrhea

Difficulty in urinating

Leg/calf pain

Numbness on my toes and feet

Fatigue

Stress/ anxiety

“Thank you for your time answering this questionnaire”