IMU Bukit Jalil – ME213 G1
__________
GENERAL SOCIO-DEMOGRAPHY / SOSIO-DEMOGRAFI LAZIM
1. Name / Nama
2. Date of birth / Tarikh lahir
3. Gender / Jantina
4. Race / Bangsa
5. Marital status
Status perkahwinan
6. Number of children
Bilangan anak
7. Number of household members
Bilangan ahli keluarga
8. Highest degree or level of school
you have completed:
Tahap pendidikan anda:
9. How many years have you been
living here?
Berapa tahun anda tinggal di
kawasan perumahan ini?
10. What is your current monthly
household income?
Berapakah pendapatan anda
setiap bulan?
FORM NO.
: __________________________________________________
Day / Hari: _____ Month / Bulan: _____ Year / Tahun: _____
o Male / Lelaki
o Female / Perempuan
o Malay / Melayu
o Chinese / Cina
o Indian / India
o Others / Lain-lain: ____________________
o Single / Tunggal
o Married / Berkahwin
o Divorced / Bercerai
o Separated / Berpisah
o Widow / Janda
: ____________________
: ____________________ members / ahli
o No schooling completed / Tidak bersekolah
o Primary school (UPSR) / Sekolah rendah
o High school (SPM) / Sekolah tinggi
o Pre-U College level (A-level, SAM, IB, STPM) / Pra-U Kolej
o Diploma / Diploma
o Bachelor’s degree / Ijazah sarjana muda
o Master’s degree / Ijazah sarjana
o Professional degree/ Ijazah profesional
o Doctorate degree / ijazah doktor falsafah
: ____________________ years / tahun
: RM _________________ per month / sebulan
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IMU Bukit Jalil – ME213 G1 FORM NO. __________
WORKING ENVIRONMENT / SUASANA PEKERJAAN

11. Occupation : ____________________

Pekerjaan

12. Number of years in current occupation : ____________________ years / tahun

Bilangan tahun dalam bidang pekerjaan sekarang

13. Are you aware of any health risk related to your o Yes / Ya
work? Please specify / Sila nyatakan:
Adakah anda sedar tentang sebarang risiko ________________________________________
kesihatan yang terlibat dalam pekerjaan anda? o No / Tidak

14. Have you ever suffered from work related sickness o Yes / Ya
or injury? Please specify / Sila nyatakan:
Pernahkah anda mengalami trauma atau ________________________________________
kecederaan berkaitan dengan pekerjaan anda? o No / Tidak

PEST CONTROL / KAWALAN PEROSAK

15. Are any pests a problem in and around the house?

Adakah wujudnya masalah perosak di kawasan perumahan anda?
o Yes / Ya
Please specify / Sila nyatakan: ____________________
o No / Tidak

16. How many times is fogging activity carried out in your neighborhood per month?
Berapa kali aktiviti pengasapan dijalankan di sekitar kawasan perumahan anda setiap bulan?
__________ per month / setiap bulan

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IMU Bukit Jalil – ME213 G1 FORM NO. __________
FOOD, NUTRITION AND HEALTH / MAKANAN, KHASIAT DAN KESIHATAN

17. Your daily diet consists of? (Please tick in circle) 20. Is there any other member in your household that
Diet anda terdiri daripada? (Sila tanda dalam smokes?
bulatan) Adakah sesiapa dalam keluarga anda yang juga
o Meat only / Daging sahaja merokok?
o Vegetable only / Sayur-sayuran sahaja o Yes / Ya
o Meat and vegetable /Daging dan sayur- o No / Tidak
sayuran
a. If “Yes”, how many members in your
household that smokes?
18. Anyone in the family suffers from a chronic Jika “Ya”, berapa orang dalam keluarga anda
disease? yang merokok?
Adakah ahli keluarga anda yang menghadapi __________ members / ahli
penyakit kronik?

a. How many family members? 21. Do you consume any alcohol?

Berapa bilangan ahli keluarga? Adakah anda mengambil minuman keras?
__________ members / ahli o Yes / Ya
*If none, ignore the next question o No / Tidak
*Jika tiada, abaikan soalan berikutan
a. If “Yes”, how often do you drink alcohol?
b. Please specify the diseases. Jika “Ya”, berapa kerap anda mengambil
Sila nyatakan penyakit-penyakit tersebut. minuman keras?
o Diabetes mellitus / Kencing manis __________ per week / seminggu
o High blood pressure / Tekanan darah
tinggi b. If “Yes”, what type of alcoholic drinks?
o Asthma / Asma Jika “Ya”, apakah jenis minuman keras
o Osteoporosis / Osteoporosis tersebut?
o Heart disease / Penyakit jantung o Beer / Bir
o Others: Please state / Lain-lain: Sila o Whisky / Wiski
nyatakan o Wine / Wain
o Others / Lain-lain

19. Have you ever smoked?

Pernahkah anda merokok? 22. Is there any other member in your household that
o Yes / Ya consumes alcohol?
o No / Tidak Adakah sesiapa dalam keluarga anda yang juga
mengambil minuman keras?
a. If “Yes”, how many years have you been o Yes / Ya
smoking? o No / Tidak
Jika “Ya”, berapa tahun anda merokok?
__________ years / tahun
23. Frequency of exercising per week:
b. If “Yes”, how many cigarettes do you smoke Kekerapan anda bersenam seminggu:
per day?
Jika “Ya”, berapa batang rokok anda __________ times per week / kali seminggu
menghisap setiap hari?
__________ sticks per day / rokok sehari

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IMU Bukit Jalil – ME213 G1 FORM NO. __________
HEALTH SEEKING BEHAVIOUR / TINGKAH LAKU UNTUK KESIHATAN

24. If you are sick, do you seek medical assistance? 26. Do you go to the health clinic / hospital for annual
Jika anda sakit, adakah anda mendapatkan health checkup?
bantuan perubatan? Adakah anda pergi ke klinik kesihatan / hospital
o Yes / Ya untuk pemeriksaan kesihatan setiap tahun?
o No / Tidak o Yes / Ya
o No / Tidak

25. Where do you normally seek for medical

assistance? (Please tick circle)
Di manakah anda selalu mendapat bantuan
perubatan? (Sila tanda dalam bulatan)
o Government clinic / Klinik kerajaan
o Private clinic / Klinik swasta
o Traditional medicine / Perubatan traditional
o Others / Lain-lain: ____________________

END OF QUESTIONNAIRE / TAMAT BORANG SOAL SELIDIK

THANK YOU / TERIMA KASIH

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