Heart Disease

Kimble S. Diaz

A. Personal Data

Direction: Fill out the information below. Please dont leave it blank.
Name: ________________________________ (optional)
Age:________ years old
Address:_______________________________
Birthday:____________
Tel. no./Cell no.:__________________
Religion: _______________________
Occupation:_____________________
Direction: Put a check on your answer.
Gender/Sex:___F ___M
_____ Elementary
_____ High school
_____ College
B.1.1 Recognition Type
a. Multiple Choice
Direction: Encircle the letter of your answer.
1. In your own opinion which country is now leading in death rate because of
heart disease?
a. US
b. China
c. Japan
d. Korea
2. What kind of disease can kill you?
a. Heart disease
b. Atherosclerosis
c. Arternal disease
d. Hypertension
3. What types of interventional procedures are used in Angioplasty?
a. Balloon Angioplasty
b. Stent
c. Rot ablation
d. Atherechory

4. What are the causes of heart failure?

a. Myocarditis
b. Pericarditis
c. Pregnancy
d. Chronic hypertension

5. At
a.
b.
c.
d.

what age a person usually dies because of heart disease?

65-75
80-85
40-45
50-60

B. Degree of Judgement
Direction: Put a smiley face ( ) on your answer.
1. Do you agree that cardiovascular is the top disease in our country?
_____Strongly Agree
_____ Agree
_____ Fairly Agree
_____ Disagree
2. Do you agree that heart disease is very dangerous to people?
_____Strongly Agree
_____ Agree
_____ Fairly Agree
_____ Disagree
3. Do you agree that 50% of people die because of heart disease?
_____Strongly Agree
_____ Agree
_____ Fairly Agree
_____ Disagree
4. Do you agree that heart disease is known in our country?
_____Strongly Agree
_____ Agree
_____ Fairly Agree

_____ Disagree

5. Do you agree that heart disease known is a deadly disease?

_____Strongly Agree
_____ Agree
_____ Fairly Agree

_____ Disagree

C. Multiple Response.(More than two answers can be chosen)

Direction: Put a check () on your answer.
1. What are the types of heart disease?
___ Atherosclerosis ___ Arterial Disease ___ Hypertension
2. What are the heart diseases do you know?
___ Coronary Heart Disease
___ Arrhythmia

___ Rheumatic Heart Disease

___ Inflammatory Heart Disease

3. What age brackets do you think will likely to have heart disease?
4. ___ Infants (Below 1 year old)
5. ___ Toddlers (1-4 years old)
6. ___ Kids (5-12 years old)
7. ___ Teens (13-18 years old)
8. ___ Adults
9.
10.Who do you think is likely to have a heart disease?
11.___ Mother
12.___ Father
13.___ Children
14.
15.Which do you think are the factors that can cause heart disease?
16.___ Stress
17.___ Pollution
18.___ Unhealthy diet
19.___ Lifestyle
20.___ Others; please specify: _________________
21.
22.What do you think are the symptoms of a heart disease?
23.___ Chest pain
24.___ Dizziness
25.___ Back pain
26.___Irregular Heart beat
27.___ Others; please specify: _________________
28.
29.Where do you go or consult if you have a heart disease?
30.___ Medical Physician
31.___ Mother
32.___ Herb doctor or Albularyo
33.___ Hospitals/Clinics
34.___ Others; please specify: _________________
35.
36.What do you think are the effects of having a heart disease?
37.___ High blood pressure
38.___ Hypertension
39.___Stroke
40.___ Chest pain
41.___ Others; please specify: _________________
42.
43.
44.
45.What do you think are the foods that can cause you having a risk of heart
disease?
46.___ Junk foods
47.___ Fatty foods
48.___ Fast foods
49.___ Vegetables
50.___ Fruits
51.___ Others; please specify: _________________

52.
53.What do you think are the ways to prevent heart diseases?
54.___ Have a regular exercise
55.___ Have a proper and healthy diet
56.___ Avoid polluted areas/places.
57.___ Eat your comfort foods
58.___ Others; please specify: _________________
59.
D. Reasoning
60.Direction: Answer the following question.
61.
1. What do you think are the causes of having a heart disease?
62.________________________________________________________________
63.
64.
65.
2. How can you prevent heart disease?
66.
67.
68.
3. What do you think are the possible cure for heart disease?
69.
70.
4. Who do you think is more likely to have the risk of having heart disease?
Why?
71.
72.
73.
74.
5. Does obesity consider to be a big factor on having the risk of having heart
disease? Why?
75.
76.
6. Do you think it is necessary to have regular checkups? Why?
77.
78.
79.
80.
7. Do you think having knowledge about heart disease can help you prevent
it? Why?
81.
82.
83.
84.
85.

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90.

Respondents Signature