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Running head: HEALTH QUESTIONNAIRE 1
Health Questionnaire
Student Name:
Institution:
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HEALTH QUESTONNAIRE 2
Introduction
The selected topic is health for adults above 30 years in the United States of America.
The main purpose of the research study is to establish how both men and women aged above 30
years tale care of their health and their respective health status.
Questions
1. Age and health are related in one way or another. Which age bracket does your age lie?
a. 30-35
b. 36-41
c. 42-47
d. 48-53
e. 54-59
f. 60-65
g. 66+ years
2. What is your gender? Circle one
a. Male
b. Female
3. What is your marital status? Please tick only one
a. Single
b. Engaged
c. Divorced
d. widowed
4. When was the last time you fell sick ?
a. Less than a month ago
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HEALTH QUESTONNAIRE 3
b. Between 1 and 3 months
c. More than 3 months ago
5. Do you have a personal doctor?
a. Yes
b. No
6. How frequently do you visit the doctor?
a. Weekly
b. Monthly
c. Less frequently
7. What is the doctor’s field of specialization?
a. General physician
b. Gynecologist
c. Other (specify)
8. Kindly rate local health clinic service delivery in a scale of 1-5 below
a. 5- Excellent
b. 4 Good
c. 3 Fair
d. 2- Poor
e. 1- Very poor
9. How would you rate your overall health status?
a. Very healthy
b. Healthy
c. Unhealthy
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HEALTH QUESTONNAIRE 4
d. Not sure
10. Do you have a insurance medical cover?
a. Yes
b. No
11. Who does home chores in your house?
a. Myself
b. I seek help from someone
c. I have a house girl
12. What is your employment status?
a. Employed
b. Unemployed
c. Retrenched
13. Do you participate in any sport?
a. Yes
b. No

Unformatted Attachment Preview

Running head: HEALTH QUESTIONNAIRE Health Questionnaire Student Name: Institution: 1 HEALTH QUESTONNAIRE 2 Introduction The selected topic is health for adults above 30 years in the United States of America. The main purpose of the research study is to establish how both men and women aged above 30 years tale care of their health and their respective health status. Questions 1. Age and health are related in one way or another. Which age bracket does your age lie? a. 30-35 b. 36-41 c. 42-47 d. 48-53 e. 54-59 f. 60-65 g. 66+ years 2. What is your gender? Circle one a. Male b. Female 3. What is your marital status? Please tick only one a. Single b. Engaged c. Divorced d. widowed 4. When was the last time you fell sick ? a. Less than a month ago HEALTH QUESTONNAIRE b. Between 1 and 3 months c. More than 3 months ago 5. Do you have a personal doctor? a. Yes b. No 6. How frequently do you visit the doctor? a. Weekly b. Monthly c. Less frequently 7. What is the doctor’s field of specialization? a. General physician b. Gynecologist c. Other (specify) 8. Kindly rate local health clinic service delivery in a scale of 1-5 below a. 5- Excellent b. 4 – Good c. 3 – Fair d. 2- Poor e. 1- Very poor 9. How would you rate your overall health status? a. Very healthy b. Healthy c. Unhealthy 3 HEALTH QUESTONNAIRE d. Not sure 10. Do you have a insurance medical cover? a. Yes b. No 11. Who does home chores in your house? a. Myself b. I seek help from someone c. I have a house girl 12. What is your employment status? a. Employed b. Unemployed c. Retrenched 13. Do you participate in any sport? a. Yes b. No 4 Name: Description: ...
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