quesstionnaire - GENERAL QUESTIONNAIRE This survey is...

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GENERAL QUESTIONNAIRE This survey is strictly for research purpose and the information you provide would be kept confidential Please answer all the questions. This would help us to resolve health care issue faced by women. Tick mark ( √) wherever applicable. NAME: _____________________/__________________________/___________________ ( SURNAME) ( FIRST NAME) (MIDDLE INIAL) Male Female DOB : ___/___/___ (mm / dd/ yy) Age :____ ( It is essential that you please fill this blank) Marital status : Married / Living with a partner/ Widowed, divorced/ Never married. How many children have you delivered? 1 2-4 More than 5 How old are your children? Less than 12 yrs. 12-18 yrs. more than 18 yrs. Employment status: Working women- part time/ Working women- full time/ House-wife Education status : College graduate/ Post high school/ High school/ High school incomplete. Do you enjoy your work? Yes No I don’t work. Family income: less than 20000$ 20000-40000 40000-60000 More than 60000. 1
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GENERAL HEALTH How would you describe your health: Excellent Very good Good Fair Poor How satisfied are you with the overall health care system? very satisfied neutral not satisfied Are you concerned about the quality of care given by the health care system? Yes
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This note was uploaded on 10/24/2011 for the course MGMT 600 taught by Professor Dr.pal during the Spring '11 term at St. Johns Duplicate.

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quesstionnaire - GENERAL QUESTIONNAIRE This survey is...

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