B.Sc.

Sem-5
Roll no-133
Name-Dharam J Daxini

Prepare a questionnaire

People's attitude towards family Planning

Please note that responses are completely confidential and we do not share the
information. Your responses are voluntary and are classified. Please answer
honestly. Please tick mark your reply.

[A] Personal Details:

1. What is your name

2. Age group (years)

• <20

• 20-25

• 26-35

• 36-45

• 46-55

3. Marital Status

• Single Married

• Separated

• divorced

• Widowed

• Undisclosed

4. Religion

• Hindu

• Islam
 • christianity

• Undisclosed

5. Highest level of Education

• No formal Education

• Primary

• Secondary school

• Diploma

• Degree

• Doctoral

• Undisclosed.

6. Occupation

• Farming

• artisan

• Trading business

• Public Servant

• Private Sector worker.

• Self employed

• Teaching

• Unemployed

• Undisclosed

7. Monthly income

• Less than ₹5000

 • ₹5000-₹18000

• ₹18001-₹30,000

• ₹50,001-₹80,000

• ₹80,001-₹100,000

• ₹100,000-200,000

• ₹200,001-₹300,000

• Greater then ₹300,000

• Undisclosed

[B] knowledge About family Planning

8. Main source of information about family planning

• private hospital Health Consent

• Mosque

• Government-owned Health Personal

• Not-for-profit organisation. church

• Printed Media (poster , handbill) electronic Media (Radio, television)

• Undisclosed

9. Main reason for choice of joining planning method

• Affordability

• Availability

• Effectiveness Reliability

• Little on No side effect

• No reason(arbitrary choice)
10. Main Reason for not using any family planning method

• Main Side effects

• Desire for more children

• Husband's disapproval

• No specific reason

11 . Duration of family planning use (years)

• <1

• 1-3

• 4-6

• 7-10

• >10

12. Family planning method decider

• Both

• Wife

• husband

13. Known side effects

• None

• Weight gain

• weight loss

• Heavy Menstrual period

• Irregular menstrual period

• Condom burst
 • Secondary infertility

• Undisclosed

[C] Women's Knowledge about reproductive Health:

14. Have heard about reproductive health?

• yes

• No

15. If answer is yes,

where did you hear about it?

• Television Radio

• Physical nurse counsellor

• Relative

• friends

16. Is the period between consecutive Pregnancies important?

• Yes

• No

17. Is Perinatal care essential ?

• Yes

• No

18. Is breast feeding the same as bottle feeding ?

• Yes

• No

19.Are you going to advise your daughter to have Premarital examination ?

• Yes
 • No

[D] knowledge of and attitude to HIV infections and Aids :

20.Have you ever heard about Aids ?

• Yes

• No

24 What do you think is the cause of the AIDS ?

• Microbe

• Fungus

• other

• Unknown

22. What is AIDS?

• Infection disease

• Cancer

• Normal decease

23 Can we Avoid AIDS intuitions?

• yes

• No

24 Is there a treatment tor AIDS?

• Yes

• No

• Don’t know

25 Should we segregate AIDS Patients form Society?

 • Yes

• No

26. Do all HIV-infected people die ?

• Yes

• No

• Don't know

27 Do you think that there are disease transmitted by sex between married
couples ?

• Yes

• No

• Don't Know

28. Does the use of condoms prevent this disease?

• Yes

• No

• Don't know

29 What can we do to prevent infection by this disease ?

• Health educating and information campaign

• Periodic medical examination.

• Premarital examination

• Early treatment of disease

• Don't know

30 How do people get infected by AIDS?

• Having sex with infected Person

• Infected blood

• Using infected needles

• Insect bites

• Normal Daily Contact

• Swimming Pools /Toilet

• others