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Questionnaire On Conjunctivitis

This document contains a questionnaire to collect information about cases of recent pink eye (conjunctivitis). The 30-question survey collects demographic data like name, age, occupation and contact information. It asks about symptoms experienced like redness, discharge, irritation and duration. It also inquires about potential causes or risk factors such as contact with other sick individuals, contact lens use, swimming pool use, hand washing and vaccination history.

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390 views3 pages

Questionnaire On Conjunctivitis

This document contains a questionnaire to collect information about cases of recent pink eye (conjunctivitis). The 30-question survey collects demographic data like name, age, occupation and contact information. It asks about symptoms experienced like redness, discharge, irritation and duration. It also inquires about potential causes or risk factors such as contact with other sick individuals, contact lens use, swimming pool use, hand washing and vaccination history.

Uploaded by

Quiz PAU
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Questionnaire on Recent Pink Eye (Conjunctivitis)

disease

a) Name: ___________________________________________________

b) Gender: Male/Female/Others (put a tick mark)

c) Phone/Email: _______________________________

d) Age: I) up to 25 Yrs. ii) 26 - 30 Yrs. iii) 31 - 40 Yrs. iv) 41 - 50 Yrs. v) More than 50 Yrs.

e) Occupation: ______________________________________________________________

f) Institute:

g) Address: _________________________________________________________

h) Approximate amount of income (monthly family income) : a) <BDT 10,000 b) BDT 10,000 - 20,000

I) BDT 21,000 - 40,000 d) BDT 41,000 - 60,000 e) BDT 41,000 - 60,000 f) More than BDT 60,000

j) Level of education: a) <S.S.C b) S.S.C c) H.S.C d) ≥Graduated

QUESTIONNAIRE
1. Do you affected with red eye recently ?
a) Yes
b) No
2. If so, Redness was present in
c) One eye
d) Both eyes
3. Duration of Redness
a) 1 to 3 days
b) 4 to 6 days
c) 7 to 10 days
d) 11 to 14 days
e) More then 14 days

4. Swelling of eyelid /Conjunctiva ?


a) Yes b) No
5. Discharge was present
a) Yes b) No
6. Discharge type was ….?
a) Watery
b) Mucoprulent / Thick
7. Excessive tear production?
a) Yes b) No
8. Discharge of –
a) Pus
b) Mucus
c) Both
9. Do your Eyelids stick together during awake morning?
a) Yes
b) No
10. Crusting of eyelids or lashes, especially in the morning?
a) Yes b) qNo
11. Itching, irritation, and/or burning and/or feeling like a foreign body in the eyes?
a) Yes
b) No
12. Do you feel difficult to watch during high light/ photophobia?
a) Yes
b) No
13. Do you have come contacted with any red eye patients?
a) Yes
b) No
14. If yes, how many days did you come into close contact with an infected person before the
onset of symptoms?

15. If you are cured, what was the duration (days) of your illness?

______________________________________________________________________
16. Have you ever contacted your eyes with vaginal fluid?
a) Yes b) No
17. Symptoms of a cold, flu, or other respiratory infection?
a) Yes b) No
18. Ear infection with eyes problem
a) Yes
b) No
19. Are there any other family members infected?
a) Yes
b) No
20. Do you wear contact lenses?
a) Yes
b) No
21. If yes, do you clear your lens properly?
a) Yes
b) No
22. Do you have allergic conditions like- fever, asthma, and eczema?
a) Yes
b) No
23. Do you work in places with smoke, dirt, dust, chemical vapors, and pollens?
a) Yes
b) No
24. Do you use swimming pools for bathing?
a) Yes
b) No
25. Do you wash your hand with soap before and after cleaning, or applying eye drops or ointments to
your eyes?
a) Yes
b) No
26. Do you use water on your eyes to feel better?
a) Yes
b) No
27. What do you prefer for treatment?
a) Allopathy
b) Homeopathy/ Ayurveda
28. Are you vaccinated against these?
a) Rubella
b) Measles
c) Chickenpox
d) Shingles
e) Pneumonia
f) Haemophilus influenza type b (Hib)
29. Are you vaccinated against Covid-19?
a) Yes b) No
30. If yes, how many doses are completed?
a) Single
b) Double
c) Booster

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