SURVEY QUESTIONNAIRE

This questionnaire is an important part of the research which aims to evaluate the effects of
chronic disease to patients and to their family members. Your participation in this survey is crucial in
order to be able to determine the experiences and coping up on their current conditions. The data
collected for this survey is strictly confidential and the information collected will be used for statistical
purposes only; all information will remain anonymously. Kindly provide the accurate information.

PART I

Socio-Demographic Data
Directions: Please check answers as appropriate. Thanks in advance for your anticipated
cooperation.

Age:

Sex: ___Male ____Female

Marital Status: ____Single ____Married ____separated or divorced ____widowed

Profession:

Religion:
PART II

What health concerns do you have?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How long since you have been diagnosed with chronic disease by a health care professional?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How would you describe your emotions after being diagnosed?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Are there some differences in living your life after knowing about your illness?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How would you describe your daily experience having that illness?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What ways did you cope up with your chronic condition?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

What makes it better? What makes it worse?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How does your condition affect your self-confidence?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Did you take any medication for your long-term illness or chronic conditions?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How does your chronic condition affect your participation at school/work?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Were you fearful and discouraged about your future, knowing that you have been diagnosed with chronic
illness?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

How does your condition affect your relationship with your family members?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________