QUESTIONNAIRE

Good day! We are the fourth year students of Pamantasan ng Lungsod

ng Marikina College of Nursing. We would like to ask a little of your precious
time to help us accomplish our thesis on Stressors and Coping Mechanisms
of Hospitalized Middle Adults in Selected Hospitals. Your cooperation and
honesty in answering the following questions would be very much
appreciated.

PART I: DEMOGRAPHIC PROFILE

A. Name (optional):
___________________________________________
B. Age:
____________________________________________________
C. Date of Birth:
______________________________________________
D. Sex:
( ) Female ( ) Male
E. Civil Status:
( ) Single ( ) Married ( ) Separated ( ) Widowed
F. Religion:
_________________________________________________
G. Family Type:
( ) Nuclear ( ) Extended
H. Number of Children:
________________________________________
I. Occupation:
______________________________________________

Do you experience stress during your hospital stay?

( ) Yes (Proceed to PART II) ( ) No

PART II:
Which of the following do you consider as contributory factors to your stress?
Check all that apply:

A. Financial
( ) Low budget
( ) Lack of financial support from relatives
( ) No savings for hospitalization
( ) Jobless
( ) Too many expenses
( ) Others (Pls. specify): __________________________________________

B. Environment
( ) Untidy surroundings
( ) Noises from other patients or rooms
( ) Lack of privacy
( ) Unfamiliarity of the surroundings
( ) Others (Pls. specify): __________________________________________

C. Health Care Team

( ) Too busy nurses and doctors
( ) Health care team members' use of unfamiliar words
( ) Not having questions answered by the staff
( ) Not knowing the results of or reasons for treatments
( ) Not being informed about your condition
( ) Others (Pls. specify): __________________________________________

D. Internal/Personal Factors
( ) Having unexpected hospital confinement
( ) Being dependent of medications
( ) Being hospitalized because of an accident
( ) Not knowing when to expect things to be done to you
( ) Thinking of experiencing pain from procedures
( ) Others (Pls. specify): __________________________________________

E. Family Related
( ) Worried about your children
( ) Lack of visitors
( ) Missing spouse

PART III:
What do you usually do to deal with stress? Check all that apply:

( ) Talking to other patients

( ) Talking to nurses
( ) Watching television
( ) Listening to the radio
( ) Calling/texting family/friends
( ) Reading books/newspapers/magazines
( ) Playing games
( ) Surfing the internet
( ) Walking around the hospital
( ) Writing on a diary
( ) Praying
( ) Others (Pls. specify): __________________________________________