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Sample Questionnaire

Sample Questionnaire

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Published by Audi Kyle Saydoven

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Published by: Audi Kyle Saydoven on Feb 28, 2010
Copyright:Attribution Non-commercial


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PERSONAL INFORMATIONA.Name (optional): _________________________Instruction: Please put check mark (
) on the space provided that coincides withyour personal data.B.Age: ____ Below 25 years old ____ 25 - 40 years old ____ Above 40 years oldC.Religion: ____ Catholic ____ Non – CatholicD.Occupation: ____ Employed ____ Self – employed ____ UnemployedE.Highest Educational Attainment ____ Elementary Level ____ High school level ____ College Level
Listed below are cultural beliefs involved in maternal and newborn healthcare. The following cultural beliefs are grouped into three: a) During pregnancyand b) During child delivery and c) After child deliveryCULTURAL BELIEFSInstruction:
Left column of the table:Please put a
check mark 
) in the appropriate boxes of thecultural beliefs on maternal and newborn health care you are still
practicing at present
Right Column of the table:Please put a
check mark 
) in the appropriate boxes of the beliefson maternal and newborn health care that best represents
extent of practice
1 = Never 
2 = Often
3 = AlwaysDuring Pregnancy(
Extent of Practice
Conceiving mother should not go around looking upto fruit bearing trees and /or desiring the fruits.
Pregnant woman should not open the “lutsen”(gourd used in storing salted pork) while her husband is away.3.Avoid eating twin fruits.
During pregnancy, both husband and wife shouldnot travel to other places outside their barrio / barangay.
Husband and wife should avoid going to hot springor cold springs.
Husband and wife should never criticize, mock, or laugh at a person with physical defect.7.The pregnant woman is given only anything shedesires in the house as long as her husband isaround.
Pregnant woman is not allowed to butcher animalsin absence of their husband.9.When the expectant mother feels her labor painswhile out of the house, she should try to make it back home.During Child Delivery(
Extent of Practice
1231.When labor pains starts, she must walk around andkeep herself busy to keep off her mind from the pain.
When the labor is too much prolonged and difficult,a traditional healer (insup - ok) will be called.
Traditional midwife will be called to help themother deliver the baby. The traditional midwifeand the giving birth mother are the only onesallowed to stay in a room where the mother feelsshe is comfortable to give birth.
The farey (placenta) should be wrapped with clothor be placed in a container and will be buried on theleft hand side of the doorway facing outside if thechild is a girl. If it is a boy, the placenta will be buried on the right hand side of the doorway.
The position of the child when it came out should be noted.

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