QUESTIONNAIRE

Code Number: ______________

Part I. Socio-demographic Profile

1. Age: _____________

2. Position in the Family

a. Mother ( )

b. Father ( )

3. Occupation: _____________

4. Educational Attainment:

a. Primary ( )

b. Secondary ( )

c. Tertiary ( )

5. Religion: _____________

6. Family Monthly Income:

> 3001 and above ( )

> 2501 – 3000 ( )

> 1501 – 2500 ( )

> 1001 – 1500 ( )

> 501 – 1000 ( )

> 100 – 500 ( )

Part II. Health Related Beliefs and Practices

Direction:

Kindly indicate your response, idea and point of view to the

questions honestly by putting check mark corresponding to your health

beliefs and practices.

A. Health Promotive Behaviors/Measures

Our family prevents diseases by:

Health Promotive Behaviors/Measures 4 3 2 1
Alway Often Seldo Never
s m
1.Maintaining cleanliness inside and outside
our home
2. Eat nutritious foods or have a balanced
diet
3. Washing hands before and after meals
4. Proper personal hygiene
5. Having a regular exercise
6. Not smoking
7. Not drinking liquor
8. Ensuring clean and safe water sources
for drinking
9. Proper and complete immunizations
10. Taking vitamins and food supplements
11. Regular check-up
12. Attending health education or seminars
about health
13. Wearing/using charms, amulets or
anting-anting
14. Recognizing the existence of
supernatural being
15. Washing wounds with herbal
preparations
16. Consulting physician
17. Isolating sick member
18. Sterilizing food utensils
19. Taking rest
20. Taking medications
21. Regulating activities
 B. Curative/Remedial Measures

Diseases/ illnesses are cured/treated by:

Curative/Remedial Measures 4 3 2 1
Alway Often Seldom Never
s
1. Bed rest
2. Monitoring body temperature
3. Proper hygiene (for e.g. in
taking care of wound)
4. Provide easy to digest food
like hot soup/lugaw
5. Applying therapeutic
procedures such as sponge
bathing
6. Taking medicine even
without prescription from the
doctors
7. Taking medicines with
prescription form doctors
8. Seeking medical consultation
9. Using herbal medicines like
aloe leaf, ginseng, lakad
bulan
10. Praying to alleviate pain or
treat diseases
11. Performing rituals to cure
the sick such as orasyon
12. Submitting a sick person to
santiguar/himotbot
13. Submitting as sick person to
hilot or massage
14. Submitting a sick person to
hinibang/sibang
15. Providing an offering or
pag-aalay for the
supernatural creatures to
cure a certain illness
Part III. What are the Health Seeking Related Problems
Encountered?

Direction:

Kindly rank your answer according to the most encountered

problem in seeking medical consultation wherein;

1 – Most encountered

7 – Least encountered

________ Inadequate health facilities in the Barangay

________ Poor transportation

________ Lack of family budget

________ Unawareness to signs and symptoms of certain disease

________ Lack of trust to medical professional due to past experiences

________ Unavailability of medical health practitioners in the Barangay

________ Lack of medical assistance from the government