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Health Survey Questionnaire

The document is a health survey questionnaire that assesses overall health, factors leading to hypertension, fever, and diabetes. It includes a series of questions with rating scales and yes/no options to evaluate health conditions and lifestyle habits. Participants provide optional personal information such as name, age, and gender.

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hmxugh.7
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9 views1 page

Health Survey Questionnaire

The document is a health survey questionnaire that assesses overall health, factors leading to hypertension, fever, and diabetes. It includes a series of questions with rating scales and yes/no options to evaluate health conditions and lifestyle habits. Participants provide optional personal information such as name, age, and gender.

Uploaded by

hmxugh.7
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Health Survey Questionnaire

Name: _____________________(optional) Age:____ Gender:____ Date:________

A. Health Assessment
On a scale of 1-5, with 1 being poor and 5 being excellent, check the box that most closely
describes your health situation.
1 2 3 4 5
Very Poor Poor Average Good Very Good

Health Assessment 1 2 3 4 5
1. How would you rate your overall health?
2. How well do you engage in physical exercise?
3. How well do you sleep at night?
4. How would you rate your current diet?
5. How well do you maintain good health?

B. Factors leading to Hypertension


1. Have you heard of hypertension (High Blood Pressure) before? Yes / No ____
2. Do you know what blood pressure is and how it is measured? Yes / No____
3. Have you experienced any symptoms that could indicate hypertension? (check all that apply)
___Headaches ___Dizziness ___Chest pain ___Shortness of breath ___Vision problems
C. Factors leading to Fever
On a scale of 1-5, with 1 being never and 5 being always, check the box that most closely
describes your health condition.
Questions Never Seldom Sometimes Often Always
1. How often do you experience having fever in a
year?
2. Did you ever seek medical help for a fever?
3. How often do you engage in activities that may
result in physical stress or overheating that leads to
fever?
4. How often do you come in contact with
individuals who have a fever?
6. How often do you take medications to manage
your fever?

D. Factors leading to Diabetes


1. Do you have a family history of diabetes (from grandparents, parents, or siblings)? Yes / No ____
2. Are you physically active on a regular basis? ___Sedentary ___Occasionally active ___Very active
3. How often do you monitor your blood sugar levels? __Never __Rarely __Sometimes __Regularly
4. Do you experience frequent urination, excessive thirst, sudden weight loss or fatigue, which may
indicate symptoms of diabetes? Yes / No ____
5. What is your current body mass index (BMI) range?
___Underweight ___Normal Weight ___Overweight ___Obese

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