Professional Documents
Culture Documents
Qustionnaire Edited
Qustionnaire Edited
Investigators:
Mr B.S. S De Silva. B Sc, M Sc
Mrs N.K.R.D. Wickramasinghe. B Sc, M Sc
Mr. V.V.Sanchayan, R.N. Under graduate
Mr.R.Yuharaj, R.N. Under graduate
Mr.S.Jeyanantha, R.N.Under graduate
Date
Serial no
A) Demographic data
Please answer the question by marking () most apprpriate answer in the sheet.
You can mark more than one reponse.
08) Employment status 10) Status of BCG vaccination and scar formation
a) Unemployment Yes No
b) Government sector a) Vaccination
c) Private sector b) Scar formation
d) Self employment
e) Others 11) Is this first time do you have TB?
f) If others, occup a) Yes
b) No
If no, occurrence:
a) Infectious disease
Caused by bacteria
b)
c) Mainly afected Lungs
d) Other Body systems will
e) Complications will occur
f) Can be trasmited person
If others, specify..
29) If snacks yes, what are the snacks type take between main meals ?
2 or More
more than
than One one
2 day in day in
times Once a a Once a
a day a day week week month
a) Plain tea
b) Tea
c) PlainCoffee
d) Milk coffee
e) Fresh milk
f) Milk powder
g) Fruit juice
h) presavative bevarages
i) Natural drinks
Type Resources
PMC Own wpublic Tube wLagoons
well
a) Boiled cool water
b) without boiling
c) Filter using
a) Yes
b) No
c) No idea
52) If yes;
a) Type of vechicle Bus
Train
Two Three
Once times times
a a a Four or
Daily week week week more times
b) Frequency
Less
than 11- 61-
10 30 31-60 120 More than
Km Km Km Km 120 Km
c) Travelling disternce
54) If Yes;
How
long
Reason before
a) Business 1 month
b) Education 2 months
c) Environment 3 months
d) Fascilities 6 months
e) Powerty 9 months
f) War More than 1
Before
the
disease After the disease
Yes No Yes No
Questionnaire on examination of the factors that influencing for
tuberculosis among patients at Tubeculosis clinics in Eastern
Province
A) Demographic data
Please answer the question by marking () most apprpriate answer in the sheet. You can mark
more than one reponse.
B. knowledge on TB
1) General knowledge of tuberculosis(TB)
Before the After the
disease disease
Yes No Yes No
a) Infectious disease
b) Caused by bacteria
c) Mainly afected Lungs
d) Other Body systems will affected
e) Complications will occur
f) Can be trasmited person to person
15) If (f) is yes; This disease can be Transmited person to person by;
Yes No
a) Food
b) Sharing common house hold items
c) Using common sanitori facilities
d) Air
e) Feeding mother to children
f) Pregnant mother to baby
g) Droplets
h) Transmitted by sputum
i) Person who is getting treatment for TB infection
j) Skin contact
k) Other Methods
If others, specify..
If others, specify..
17) Do you like others know that you are suffering from TB ?
a) Yes b) No c) No idea
22) what are the activities, avoid transmission from one to others?
Yes No No idea
a) Wearing mask
b) Using separate house hold items
c) Using separate sanitary facility
d) Sputum was not spit in public place
e) Sharing dresses
f) keep hand on the mouth before coughing
g) Using of hangercheif when on coughing
23) Do you follow the following practices when you are getting treatment
Yes No No idea
a) Take treatment according to the physician
b) Attending to clinic regularly
c) Follow the instruction to avoid the
transmission of the disease during the
treatment period
d) Giving the proper sputum sample for screening
e) In addition to the western treatment are you
following any other treatment for TB
C) Nutritional factors
28) If snacks yes, what are the snacks type take between main meals ?
33) If yes, do you belive that this disease caused by family member?
a) Yes No No idea
b)
c)
39) If (e) is yes, that dairy farm managed by and disternce from your home;
More
Less 101M than
than 51M- -
Managed by 50 M 100M 250M 250M
a) Own
b) Neighbours
c) Government
d) Private companies
a) Yes b) No c) No idea
a) Yes b) No c) No idea
47) If yes;
a) Type of vechicle
Bus Train Others
49) If Yes;
1 2 3 6 9 More than 1
Reason month months months months months year
a) Business
b) Education
Environmen
c) t
d) Fascilities
e) Powerty
f) War
g) Job
If you are a health worker please don't answer following questions number 51 and 52
50) Under any conditions have you provide care to any person who are already have TB?
Yes
No
53) Have you visit refugee or displaced peoples camps with in last 4 years?
Regularly
Frequently
Occacianally
Never
54) Before suffered TB, are you Hospitalized for any other health care needs?
Yes
No