Survey-Questionnaire for Research Study Entitled “Factors Affecting Malnutrition

Among from Grade 2 to 6 Pupils in M. Cuaderno Elementary School in Sibacan Balanga City,
Bataan, School year 2010 to 2011

SURVEY QUESTIONNAIRE

To all respondents:

This questionnaire aims to determine the factors that may affect the Malnutrition among
Grade 2 to 6 Pupils in M. Cuaderno Elementary School in Sibacan Balanga City, Bataan.

Please fill the necessary data with honesty for the completion of the study. Rest assured
that you answers will be treated with strict confidentiality.

Thank you very much for your consideration.

BPSU 3rd Year Nursing Students

Researcher

Direction: Answer the following questions whenever applicable. Put a

check in the box that corresponds to your answer.

PART 1: Profile of the Respondents

Name (optional)________________________________________________

Age

6-8 years old

8-10 years old

10-12 years old

12-14 years old

Gender

Male

Female
Hygiene

Takes a bath

Always

Often

Sometimes

Seldom

Never

Others (Please Specify):__________

Brushes Teeth

Always

Often

Sometimes

Seldom

Never

Others (Please Specify):__________

Washes Hands

Always

Often

Sometimes

Seldom

Never

Others (Please Specify):__________

Diet

I eat variety of foods like meat, fish, vegetables and fruits

I love eating junk foods and candies. Everyday that’s part of my snacks.

I don’t eat vegetables

I prefer vegetables like Jollibee and McDonalds.

I drink 8 glasses of water a day.

I am having my meals three times a day

Others (Please Specify):________________________________________

PART 1: Profile of the Parents

Age

18-25 years old

26-30 years old

31-35 years old

36-40 years old

Others (Please Specify): ____________________________________________

PART III: Awareness in Public Health Programs

Are you aware of the health programs in your school and barangay?

Yes

No

If yes, what Health Programs have you participated? Please Specify.

__________________________________________________________________

PART IV: Factors contributing to malnutrition of children

How many members do you have in your family?

2-4 members

5-7 members
 8-10

Others (Please Specify): _________________________________________

Anybody in the family that is malnourished?

Mother

Father

Sister

Brother

Grand Mother

Grand Father

Others (Please Specify): _______________________________________________