DEMOGRAPHIC PROFILE

1. NAME:
2. AGE:
3. GENDER:
 MALE
 FEMALE
4. EDUCATION LEVEL:
 ILLITERATE
 PRIMARY SCHOOL
 S.S.C
 H.S.C
 GRADUATE AND ABOVE
5. OCCUPATION:
 AGRICULTURIST
 SHOP KEEPER
 UNSKILLED WORKER
 SKILLED WORKER
 PROFESSIONAL
 OTHERS
6. INCOME LEVEL(RS.)
 DEPENDENT
 BELOW 10000
 10000_30000
 30000 AND ABOVE

QUESTIONNAIRE

(A) Where do you prefer to receive

medical treatment?
 Public Health Centre
 Civil Hospital
 Private Hospital
 Ayurvedic Treatment
 Homeopathic Treatment
(B) Are you satisfied with the facilities
provided in Public Health Centre?
 Rate your answers accordingly
(1) Excellent
(2) Good
(3) Neutral
(4) Average
(5) Poor

DETERMINANTS Excellent Good Neutral Average Poor

cooperative staff
behaviourr of doctors
sitting arrangements
hygenic environment
hospitalization
environmental sanitation
immunization
precautionary measures for diseases
pre natal care
(C) Are you satisfied with the services
provided in the public health
centres?
 Highly satisfied
 Satisfied
 Partially satisfied
 Dis-satisfied
 Highly dis-satisfied

(D) VIEWS ABOUT SERVICES

1. What do you think about the
behavior of the doctors?
 Polite
 Cooperative
 Irritating
2. Are the doctors available on
regular basis?
 Regular
 Irregular
3. What do you think about the
behavior of the staff?
  Polite
 Cooperative
 Irritating
4. How are the environmental
conditions of the PHC’s?
 Hygienic
 Unhygienic
 Very poor
5. Are the equipments used for
medical treatment
sterilized?
 Yes
 No
6. Are you satisfied with the
Ante-Natal services?
 Yes
 No
7. Are prompt attendance
facilities available for
woman?
 Yes
 No

8.