QUESTIONNAIRE

1. On a scale of 1 to 10, how healthy do you consider yourself?

2. Do you currently suffer from any chronic diseases?
1. Yes
2. No
3. Do you have any hereditary conditions/diseases?
1. High blood pressure
2. Diabetes
3. Hemophilia
4. Thalassemia
5. Huntington
6. Other (Please specify)
4. Are you habituated to drugs and alcohol?
1. Yes to both
2. Only to drugs
3. Only to alcohol
4. I am not habituated to either
5. How often do you get a health checkup?
1. Once in 3 months
2. Once in 6 months
3. Once a year
4. Only when needed
5. Never get it done
6. Other
6. Overall, how do you rate the local hospitals in your area?
1. Excellent
2. Above average
3. Average
4. Below average
5. Very poor
7. How would you evaluate your overall health? Would you say you are:
1. In good physical health (No illness or disabilities).
2. Mildy physically impaired. (Minor illness or disabilities)
3. Moderately physically impaired. (Requires substantial treatment)
4. Severely physically impaired. (Requires extensive treatment)
5. Totally physically impaired. (Confined to bed)
8. In your opinion, at what capacity can you perform everyday activities?
1. Excellent capacity
2. Good capacity
3. Moderate capacity
4. Severely impaired capacity
5. Completely impaired capacity
9. In the past 24 hours, what different kinds of medications have you taken?
10. How many medications have been prescribed by your physician that you have taken in the
last 24 hours?
1. 1
2. 2
3. 3
4. 4
5. 5
6. More than 5
7. None
11. In the last 24 hours, how did you take your medicine?
1. Without help (in the right dosage and right time)
2. With some help (someone prepares the medicine or reminds you to take it)
3. Completely unable to take it
4. Other
12. Which health insurance coverage provider are you currently enrolled with?
1. Medicaid
2. Medicare
3. Affordable Care Act
4. Uninsured
5. Private health insurance
6. Other (Please specify)
13. Please state your level of agreement to the statement: Health insurance is affordable to you.
1. Completely Disagree
2. Somewhat Disagree
3. Neutral
4. Somewhat Agree
5. Completely Agree
 14. Has any of your family members been dropped out of coverage after a diagnosis of any
illness?
1. Yes
2. No
15. Has a lack of health insurance coverage made you consider one of the following?
1. Skip a doctor’s appointment
2. Cancel an appointment with the doctor
3. Postpone a doctor’s appointment
4. Not purchase medicine
5. Delay treatment
6. N/A
16. How often do you get a health checkup?
 Once in 3 months
 Once in 6 months
 Once a year
 Only when needed
 Never get it done
 Other
17. What do you say about your overall health?
 Having Good Physical Health
 Moderately physically impaired
 Severely physically impaired
 Totally physically impaired
Health Assessment Survey Questions
18. Do you have any chronic diseases?
 Yes
 No
19. Do you have any hereditary conditions/diseases?
 High blood pressure
 Diabetes
 Hemophilia
 Thalassemia
 Huntington
 Other (Please specify)
 20. Are you habitual to drugs and alcohol?
 Yes to both
 Only to drugs
 Only to alcohol
 I am not habituated to either
21. Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
 Not all
 Several days
 More days than not
 Nearly every day
22. Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
 Not all
 Several days
 More days than not
 Nearly every day
23. Over the past 2 weeks, how often have you felt little interest or pleasure in doing
things?
 Not all
 Several days
 More days than not
 Nearly every day
24. How would you describe the condition of your mouth and teeth, including false teeth
or dentures?
 Excellent
 Good
 Average
 Poor
25. How often do you have trouble taking medicines the way you have been told to take
them?
 I do not have to take medicine
 I always take them as prescribed
 Sometimes I take them as prescribed
 I seldom take them as prescribed
 26. On how many of the last 7 days did you engage in moderate to strenuous exercise
(like a brisk walk)?
 0 Day
 1 Day
 2 Days
 3 Days
 4 Days
 5 Days
 6 Days
 7 Days