Questionnaire

We, Khushboo Kayasth and Hiral Shah, the faculties of MBA Department at S.N.Patel
Institute of Technology and Research Centre, Umrakh, are conducting research on
“WOMEN AT WORK AND HEALTH ISSUES”. This study is for academic purpose
only. No information shall be disclosed anywhere. Please spare few minutes to answer
the following question:

1) Do you consider yourself to be Healthy?

[ ] Yes [ ] No [ ] Don’t Know

2) In general, what would you say about your health?

[ ] Excellent [ ] Very Good
[ ] Good [ ] Fair
[ ] Poor

3) How often do you visit your general physician?

[ ] Up to one Month [ ] 1 – 3 Months
[ ] 4 – 6 Months [ ] 7 – 12 Months
[ ] More than 1 Year

4) Which types of Health issues faced by you?

[ ] Headache [ ] Stomach disorders
[ ] Frustration [ ] Sleeplessness
[ ] Diabetes [ ] BP
[ ] Heart Disorder Others______________

5) Which factors are responsible for health Issues?

[ ] Time [ ] Junk food
[ ] Stress [ ] Gender biasness
[ ] Lack of family support [ ] Surrounding environment
[ ] Depression [ ] Over work Burden
[ ] Workplace environment Others______________

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6) Are you psychologically disturbed?
[ ] Yes [ ] No

7) Does your unhealthy mental state effect your work/family/other relations?

[ ] Always [ ] Sometimes [ ] Never

8) Which sign show your mental disturbance?

[ ] Irritation [ ] Insomnia
[ ] Depression [ ] Fatigue
[ ] Negative thoughts

9) What have you tried to improve your state of health?

[ ] Exercise [ ] Swimming
[ ] Dancing [ ] Walking in fresh air
[ ] Yoga [ ] Healthy Eating
[ ] Cycling Others______________

Personal Details:
Name:__________________________________________________
Contact No:____________________
Age:
[ ] 20 - 30 [ ] 31 - 40
[ ] 41 - 50 [ ] > 51
Income (Monthly in Rs.):
[ ] Less than 10000 [ ] 10001-20000
[ ] 20001-30000 [ ] 30001-40000
[ ] Above 40000
Marital Status:
[ ] Married [ ] Unmarried

Thank You

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