Health Survey of Selected Household of Haji Ghulam Zakarya Goth

Survey Conducted on behalf of Amna Shamima Foundation

Form No: ……………

Surveyor Name:…………..

Date of Survey:……………..

Objective: To assess the health care needs of the populace and the existing health facilities of the
area

Section 1: Basic Information

1. Name:

(First Name) _____________________

(Last Name) ______________________

2. Age: ___ years

3. Gender:

Male

Female

4. Address:

5. Contact Number:

Section 2: Household Information

6. Number of family members:

Adults (18 and above): ___

Children (below 18): ___

7. Monthly Household Income:

Less than PKR 10,000

1|Page
 PKR 10,000 - PKR 20,000

PKR 20,000 - PKR 30,000

More than PKR 30,000

8. Main source of income:

Job

Business

Daily wages

Other (Please specify) ______________________

Section 3: Health and Medical Information

9. Do you have any chronic health conditions? (e.g., diabetes, hypertension, asthma)

Yes

No

10. If yes, please specify: _______________________

11. How often do you visit a healthcare provider?

Regularly (at least once a month)

Occasionally (few times a year)

Rarely (once a year or less)

Never

12. Do you have access to the following healthcare services?

Government hospital: [ ] Yes [ ] No

Private clinic: [ ] Yes [ ] No

Community health center: [ ] Yes [ ] No

Traditional healer: [ ] Yes [ ] No

13. Are you satisfied with the healthcare services available?

Very Satisfied

Satisfied

Neutral

2|Page
 Dissatisfied

Very Dissatisfied

14. Do you or any family member face difficulty in accessing healthcare services?

Yes

No

15. If yes, please specify the reason: _______________________

Section 4: Health Practices and Awareness

16. How often do you engage in physical exercise?

Daily

Weekly

Monthly

Rarely

Never

17. Do you smoke or use tobacco products?

Yes

No

18. Do you consume gutkal?

Yes

No

19. Do you or your family members use mosquito nets or repellents?

Yes

No

20. Are you aware of any health education programs in your area?
Yes
No

21. Do you use boiled water

Yes

No

22. Have you or any family member attended any health education programs in the last year?

3|Page
 Yes

No

Section 5: Nutrition and Sanitation

23. How many meals do you eat in a day?

One

Two

Three

More than three

24. How often do you consume vegetables?

Daily

Weekly

Monthly

Rarely

Never

25. How often do you consume fruits?

Daily

Weekly

Monthly

Rarely

Never

26. What type of toilet facilities do you use?

Flush toilet

Pit latrine

Open defecation

Other (Please specify) ______________________

27. Do you wash your hands with soap before meals and after using the toilet?

Always

Sometimes

4|Page
 Rarely

Never

Section 6: Comments and Suggestions

Please provide any additional comments or suggestions regarding healthcare services in your area:

End of Survey

Thank you for your time and cooperation. Your responses will help us improve healthcare services in
your community.

5|Page