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Survey Development: Behavioral, Mental and Physical Health Domains I. General Information

This survey aims to collect information across several domains of health, including behavioral, mental, and physical health. The survey contains questions about demographics, medical diagnoses, diet, exercise habits, alcohol consumption, smoking status, sources of stress, coping mechanisms, psychosocial factors, and symptoms of depression and suicidality. Responses will provide an overview of an individual's health across several important areas.

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112 views4 pages

Survey Development: Behavioral, Mental and Physical Health Domains I. General Information

This survey aims to collect information across several domains of health, including behavioral, mental, and physical health. The survey contains questions about demographics, medical diagnoses, diet, exercise habits, alcohol consumption, smoking status, sources of stress, coping mechanisms, psychosocial factors, and symptoms of depression and suicidality. Responses will provide an overview of an individual's health across several important areas.

Uploaded by

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

SURVEY DEVELOPMENT: BEHAVIORAL, MENTAL AND PHYSICAL HEALTH DOMAINS

I. GENERAL INFORMATION
Age
Gender
Religious Affiliation
Marital Status
Number of Children (if any)
Type of Work

II. HEALTH AND WELLNESS:


A. Have you been diagnosed with any of the following?

Hypertension Epilepsy/Seizures
Diabetes Psychiatric Disorder
Cardiovascular disease Arthritis/Rheumatism
Asthma Stroke
Cancer Skin Disorders
Kidney Problems Peptic/Gastric Ulcers
Vision Problems Allergies
Anemia Others

B. Are you eating more, moderate, or less of these kinds of food?

C. How often do you undertake physical activity such as walking, jogging, or other
sports?
_____ 5-7 times a week _____ once a week
_____ 3-4 times a week _____ I do not exercise at all

slss/cfsclinic2020
III. LIFESTYLE AND LEISURE ACTIVITIES

A. Preferred activities during idle time?


_________________________________________________________________________________________________
_________________________________________________________________________________________________

B. How often do yo have a drink containing alcohol?

C. Which of the following describes you best?

 I am a non-smoker
 I am an occasional smoker
 I am a smoker trying to quit
 I quit smoking
 I am a smoker
** How many sticks a day? _____

IV. STRESS AND COPING

A. To what extent do the following stress you out?

slss/cfsclinic2020
B. How do you usually cope with the stresses and difficulties you encounter?

V. OTHER PSYCHOSOCIAL FACTORS

A. Factors that affect employees’ regular physical activity:

Long working hours


Too tired
Not offered by the company
Not sure of what activity to do
Costs associated with physical activity
Unsure of access to nearby facilities
Personal commitments
Too lazy
Not interested
Don't see how it would benefit me

B. Break time behaviors:


_____ Eat _____ Talk to colleagues
_____ Use gadgets _____ Smoke
_____ Toilet Break _____ Read

slss/cfsclinic2020
C. What stresses you the most?
_____ Work related
_____ Family related
_____ General/Health

D. Coping behavior commonly used:


_____ I pray
_____ I accept that it happened
_____ I try to make myself better
_____ I think about the best way to handle the problem

E. Depressive thoughts and behavior


_____ felt very sad, hopeless, and empty in the past month
_____ Lost interest in people or activities in the past month
_____ struggling to cope with new normal
F. Suicidal thoughts and behavior
_____ thought of taking your own life in the past 12 months
_____ Attempted to take your own life in the last 12 months
_____ physically harmed yourself without intending to take own life in the last
12 months

Thank you!

slss/cfsclinic2020

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