Download - Nres Questionnaire
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PART 1: Demographic Profle
DIRECTIONS:
How old are you? Ilang taon ka na?
18-25 years old 26-35 years old 36-45 years old 45 years or older
What is your sex? Ano ang iyong kasarian?
ale !e"ale
#i$il status
%ingle
arried &i$or'ed
Widowed
Where do you 'urrently li$e?
ontal(an arikina
)thers* +lease s+e'i,y.............
How long ha$e you (een li$ing there?
/ess than 5 years
6-10 years 11-20 years ore than 21 years
All "y li,e
Whi'h o, the ,ollowing (est des'ri(es the area you li$e in?
r(an %u(ur(an ural
du'ational Attain"ent
ndergraduate raduate ost-graduate
!a"ily onthly In'o"e in hili++ine +eso
nder 5000
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6000-10000 11000-15000 16000 and a(o$e
How long ha$e you (een working as a shoe"aker?
2-5 years 6-10 years 11-20 years 21 years and a(o$e
Whi'h o, the ,ollowing 'ategories (est des'ri(es your +ri"arily area o, e"+loy"ent
regardless o, your a'tual +osition7?
o
Whi'h o, the ,ollowing (est des'ri(es your role in industry?
o
How would you des'ri(e your work s'hedule?
o egularo Irregularo otating
How "any days in a week do you work?
o 3 days and (elowo 4 days
o 5 dayso 6 dayso days
How "any hours do you esti"ate you s+end +er day in your work?
o 3 hours and (elowo 4-8 hourso 9-12 hourso 13 hours and "ore
&o you s"oke 'igarettes?
#urrently x-s"oker )nly s"oked a ,ew ti"es :e$er
Ha$e you e$er in your li,e s"oked 'igarettes on a daily (asis?
;es
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:o
How "any years* in total* did you s"oke 'igarettes on a daily (asis?
....... ;A% %)
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x'ellent ery good ood !air oor
1 2 3 4 5
DIRECTIONS:
Buestions 1 2 3 4 5In general* how would you rate
your o$erall health now?In general* how would you rate
your o$erall "ental health now?
&o you ha$e any o, the ,ollowing 'onditions? I, your answer is ;%* "ark whether
you ne$er* +re$iously* or 'urrently re'ei$e +ro,essional treat"ent@ ro,essionaltreat"ent is any treat"ent su+er$ised (y a health +ro,essional@7
:)* I donCt
ha$e this
'ondition
;%* (ut I
ne$er re'ei$ed
+ro,essionaltreat"ent
;%* I
+re$iously
re'ei$ed (utdonCt 'urrently
re'ei$e7
+ro,essionaltreat"ent
;%* and I
'urrently
re'ei$e+ro,essional
treat"ent
#ough?
#ough with+hleg"?%hortness o,
(reath?#olds?ye irritation?Heada'he?!eeling diDDy?
>rou(le
slee+ing?
&o you ha$e any disease or health +ro(le"s (e,ore working as a shoe"aker?
;es :o
I, yes* +lease indi'ate...............
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#urrent sy"+to"s ark any o, the ,ollowing sy"+to"s you ha$e ex+erien'edwithin the last2-4 "onths
!atigue
>rou(le slee+ing Heada'he
=a'k +ain #ough
#olds %ore throat !e$er &iarrhea #onsti+ation :ausea and o"iting &iDDiness :one o, these sy"+to"s
In a ty+i'al week* on how "any days do you do any "oderate a'ti$ities that 'ausess"all in'reases in (reathing or heartrate ,or at least 30 "inutes?
3 days and (elow 4- days I donEt ty+i'ally do any "oderate exer'ise
In a ty+i'al week* on how "any days do you do any $igorous a'ti$ities that 'ausess"all in'reases in (reathing or heartrate ,or at least 30 "inutes?
3 days and (elow 4- days
I donEt ty+i'ally do any $igorous exer'ise
&o you get at least 8 hours o, slee+ at night
;es :o
Work days "issed due to illness in the +ast years?
15 or less days
20 or "ore days