Cross-Sectional Survey form for Hypertensive Patients

The questionnaire below will assess the respondents knowledge,' attitudes and on vaccination during time of
pandemic among pediatrician of James L. Gordon Memorial Hospital.
Researcher-respondents Agreement:
I (Name) ________________have been oriented on the purpose and procedures of this study. I have
read and have fully understand the questions in this survey. The researcher assured me that the information that
I will be giving will be used solely on research and academic purposes only. My identity and answers will be
kept confidential.

Signature over the Printed Name

General Instructions: Read the statements and questions carefully. With all honesty, fill in the necessary
information asked and tic/check the corresponding boxes of your answers on the statements written below.

S# First Name MI Surname

Address

Date of birth Sex Age

1. What is your marital status?

Single Married Separated/Divorced
Widowed /Widow Living-In-Relationship
2. What is your highest educational attainment?
Eleme. Graduate High school graduate
College Graduate Vocational/ technical
3. What is your current employment status? (check one box)
Working full-time
Working part-time
Consultant
Others (Please specify):
4. What is your total monthly income?
Php 5,000 and below
Php 6, 000 – Php 10,000
Php 11, 000 – Php 20,000
Php 21, 000 – & above

5. Do you test your blood sugar?

 No Yes
a. If yes, how many days a week do you test your blood sugar?
0 or not at all 5-6 days a week
1 – 2 days a week 7 days a week (daily)
3-4 days a week
b. How often do you test your blood sugar per day?
1-2 times a day 7-8 times a day
3-4 times a day 9- 10 times a day
5-6 times a day as I feel the need to do so
6. Do you keep a record of your blood sugar test results?
No Yes Only Unusual Value
7. Is there a member/s of your family with hypertension history?
No Yes
8. What is your height?
9. What is your weight?
10. What is your Body Mass Index (BMI)?
11. What is your average blood pressure in the past 2 days?
12. How many years have been hypertensive?
1-5 years
6-10 years
10-15 years
13. Do you drink alcoholic beverages? If YES please indicate how often
z NO z YES How often? ____________
14. Do you smoke? If YES please indicate how often
z NO z YES How often? ____________
15. Do you drink caffeinated beverages? If YES please indicate how often
z NO z YES How often? ____________
16. Do you exercise? If YES please indicate how and how often?
NO YES
Presence of agreed Exercise plan with physicians
Exercising According to Plan
Days per Week Doing Moderate Exercise
Intense Exercise

Patients Health Condition and Other Existing Co-morbidities

Have you experienced any of the following problems or symptoms in the last year?
Heart Problems Previous Surgery
Kidney Problems Hospital Admissions
High Cholesterol Unusual fatigue (lack of energy)
 Weight gain of more than 10 pounds Sleepiness during the day
Weight loss of more than 10 pounds Difficulty catching your breath
Pressure or discomfort in your chest Swelling of your ankles or legs
Difficulty or pain with urinating Constipation                                                   
Diarrhea Skin Rashes                          
Bad headaches Problems with your eye sight eyesight 
Poor hearing Hay fever or allergies
Pain in your joints or muscles Numbness/tingling in your hands or feet Unusual
sadness or depression Difficulty falling
Loud snoring
Have you ever had any of the following medical conditions?
Diabetes                                                          Kidney disease
Heart disease (open heart surgery, heart attack, stent placement, pacemaker, etc.)
Thyroid problems                                          Asthma
Emphysema or COPD                                  Anxiety disorder
Depression                                                     Excessive alcohol use
Anemia (low blood count)                          Arthritis

For Physician only

Height :
Weight :
BMI:
FBS :
Most Recent Value
Last appointment
Second last appointment
First appointment
RBS :
Most Recent Value
Last appointment
Second last appointment
First appointment

HbA1C in 3 months : Date :

Lipid profile
Creatinine
Others

Patient’s Name & Signature Physician’s Name & Signature