Dear Sir/ Madame:

Good Day! We are 4th year student nurses from the College of Nursing of Silliman
University currently taking up NCM 73 Nursing Leadership, Management, and
Professional Adjustment.

As part of the requirements to complete this course, we are conducting a Program

Review on Lifestyle-Related Diseases Prevention and Control Program of the DOH
among the members of the Solo Parents of Bukas Loob sa Diyos, Diocese of
Dumaguete who are Dumaguete residents. In line with this, we humbly request you to
participate in our Program Review of the said Program by answering the questionnaire.
Rest assured that confidentiality and anonymity is fully respected.

Thank you and God bless!

Truly yours,

BSN - IV (A2)
College of Nursing
Silliman University

I hereby authorize the BSN - IV (A2) student nurses to collect and process the data indicated
herein for the purpose of their Program Review of the Lifestyle-Related Diseases Program. I
understand that my personal information is protected by RA 10173 or the Data Privacy Act of
2012.
I agree to the terms and conditions….
I do not agree to the terms and conditions….
DEMOGRAPHICS: 4. Have you participated in any educational campaign or
1. Name (optional) activities on the Lifestyle-Related Diseases Program?
_____________________________________________ If yes, kindly answer the next question.
2. Age If no, kindly proceed to question #6
_____________________________________________ Yes
3. Address
No
_____________________________________________
Not sure
4. Civil Status
Single 5. What activities are being done to enforce the program?
______________________________________
Married
Widowed 6. Are you able to gain access to free health services for
Annulled your lifestyle-related disease/s?
Divorced Yes
Separated No
Prefer not to answer Not sure
If yes, what services and where? ________
5. Do you have any lifestyle-related disease/s (e.g. Diabetes,
Hypertension, Cancer, Chronic Respiratory Diseases etc.) as 7. Are you able to avail any medicines in your health center
of today? or any government agency?
If yes, kindly answer the next question. If yes, kindly answer the next question.
If no or not sure, kindly proceed to question #7. If no, kindly proceed to question #10.
Yes
Yes
No
No
Not sure
6. What lifestyle-related disease/s do you have right now? 8. If yes, what government agency and
where?_________________________
Diabetes
Hypertension 9. What medicines were you able to receive?
Cancer (any type) ______________________________________
Chronic Respiratory Disease 10. How do you manage lifestyle-related diseases in your
Prefer not to say. household?
Maintenance Medications
Others (please specify): _____________
Exercise
7. Do any of your family members presently or have a history
of the aforementioned diseases? Diet
Yes Others _________________________
No 11. How has the Lifestyle-Related Diseases Prevention and
Not sure Control Program helped improve your overall health?
Greatly Improved
PROGRAM QUESTIONS: Somewhat improved
No effect
1. Are you aware of the Lifestyle-Related Diseases
Prevention and Control Program conducted by the DOH? Somewhat worsened
If the answer is no, please proceed to number 13, if yes, Greatly worsened
proceed to 10.
12. Please rate your level of satisfaction for the following
Yes
points: (Answer options Very unsatisfied, Unsatisfied,
No Neutral, Satisfied, Very Satisfied)
Not sure

2. Where have you heard about the mentioned program?

Friends / Peers
Family
Barangay
Radio / Television
Newspaper
Social Media
Others ______

3. How is the Lifestyle-Related Diseases Prevention and

Control Program of the DOH being implemented in your 13. Do you have any suggestions / comments that will help
Community/Barangay?
improve the program?
Community gathering
______________________________________________
House to house visits
______________________________________________
Posters
______________________________________________
Online Campaigns
Others _____