COMMUNITY QUESTIONNAIRE

GROUP MEMBERS
HUMAIRA KANWAL
ZAREEN SUMBAL
MISHAL MICHAEL
PRINSLA SHAFQAT
AROOSA YOUSAF

POST RN SEMSTER -3
ISLAMABAD NURSING COLLEGE
Name: _______________ Age: ___________________
Gender: _______________ Marital status: _____________
Religion: _______________ Nationality: ________________
Occupation: _____________ Education:_________________
Race: __________________ Caste_____________________
Address:
______________________________________________________________________________
_______________

Sr. Names of family Age Relationship with head of DM HTN Others

No. members family
 1. Which type of house do you live?
A. Mud B. Cement C. Any other
2. How many rooms do you have in your house?
A. 2 B. 3 C. 4 D. Specify other
3. How many toilets do you have in your house?
A. 2 B. 3 C. 4 D. Specify other
4. How many members share one room?
A. 2 B. 3 C. 4 D. Other
5. What is the housing status of the family?
A. Own B. Rent C. Government
6. Which type of area you are living in?
A. Urban B. Rural C. Town D. Other
7. Which type of family do you have?
A. Nuclear B. Joint C. Extended D. Other
8. Do you think ,it is important to get education?
A. Yes B. No
9. What is the education system in your family?
A. Government B. Private C. Boarding D. Any other
10. Do you allow for women education?
A. Yes B. No
11. Do you allow your women to do job?
A. Yes B. No
12. How many members are earning in your family?
A. 2 B. 4 C. 6 D. If more then spcify
13. What is the main occupation of family?
A. Government job B. Private job C. Labor D. Business E. Any other
14. How much is the monthly income of your family?
A. 25000-30000 B. 30000-40000 C. 40000-5000 D. If more then specify
15. How much is the monthly expenditure of your family?
A. 20000-30000 B. 30000-40000 C. 40000-5000 D. If more then specify
16. How many members are currently dependent in your family?
A. 1-3 B. 3-5 C. 5-7 D. or specify
17. Which type of food do you prefer for your family?
A. Homemade B. junk food C. Restaurant D. Any other
18. What is the normal eating habit of your family ?
A. 3 times in a day B. 4 times in a day C. 5 times in a day D. specify other
19. Which type of diet do you prefer for your family?
A. Vegetarian B. Non Vegetarian C. Any other
20. Which type of water you are drinking in your home?
A. Tube well B. filter plant C. Mineral water D. Specify other
21. Do you store water in your home in case of emergency?
A. Yes B. No
22. How many persons share one toilet in your home?
A. 2-3 B. 3-4 C. 4-5 D. Specify other
23. Which type of severage and draining system in your house ?
A. open B. closed C . Anyother
24. which type of severage system in your localiy?
A. open B. Closed C. Specify other
25. Where you dispose your garbage ?
A. Street B. heap of garbage C. Municipal committee D. Specify other
26. Do you wash your hand with soap after toileting?
A. Yes B. No
27. Do you wash your hand with soap before eating meal?
A. Yes B. No
28. How many windows do you have in your home?
A. 2-4 B. 4-6 C. specify other
29. Do you get exposure to the sunlight
A. yes B. No
30. In case of illness where do you approach?
A. family doctor B. clinic C. Hospital D. Hakeem E. Sufi masters
31. Which first aid method do you prefer in illness?
A. Home remedies B. OTC C. approach doctor D. Specify Other
32. Do you prefer antenatal care of pregnant females in your family?
A. Yes B. No
33. How many times they get antenatal checkups throughout the pregnecy?
A. off and on B. regular C. As needed D. specify other
34. Which type of delivery do you prefer?
A. Normal B. C. Section
35. To Whom you prefer for delivery?
A. Dai B. Lhv C. Gynaecologist
36. Do you know about family planning ?
A. Yes B. No
37. Do you prefer to follow vaccination schedule for your children’s immunization?
A. Yes B. No
38. Do you have any pet ?
A. yes B. No C. if yes then specify _____________
39. Wha you use to prevent from mosquito bite or malaria?
A. mosquito net B. mosquito lotion C. Coils D. Specify other
40. Is there any member of your family smoke?
A. Yes B. No
41. Do you teach your children in family about harassment?
A. Yes B. No
42. How much sleep do you get a night?
A. 6-7 hours B. 7-8 hours C. Specify other
43. Do you take any nap in the daytime?
A. Yes B. No