HUMAN ECOLOGY AND

FAMILY SCIENCES

PROJECT
 QUESTIONNAIRE
SECTION A- [physical disabilities]
Q1- do you have problem with going to places?
a) Yes b) no c)sometimes
Q2- do people judge you when they see you have physical disabilities?
a) Yes b) no c)sometimes
Q3- do you need help with every day activities?
a) Yes b) no c)sometimes
Q4- do you have difficulty in doing basic work?
a) Yes b) no c)sometimes
Q5- do you have any problem doing school/office work?
a) Yes b) no c)sometimes
Q6- do school/office people set up any special place for you to sit and
work?
a) Yes b) no c)sometimes
Q7- do you need to use any equipment for you disabilities?
a) Yes b) no c)sometimes
Q8- do you take or need any medication for you condition to sooth any
pain or other problem?
a) Yes b) no c)sometimes
Q9- do you need to have a different diet?
a) Yes b) no c)sometimes
Q10- do you need to wear any specific clothes?
a) Yes b) no c)sometimes
SECTION B - [learning disability]
Q1- do you have a tough time concentrating on assignments?
a) Yes b) no c)sometimes
Q2- do you use any other way which might help you concentrate?
a) Yes b) no c)sometimes
Q3- do you difficulty completing work on time?
a) Yes b) no c)sometimes
Q4- do you get any headaches when trying too hard to concentrate?
a) Yes b) no c)sometimes
Q5- do you forget things easily?
a) Yes b) no c)sometimes
Q6- do you have trouble writing words or numbers correctly?
a) Yes b) no c)sometimes
Q7-do you have difficulty in talking to people?
a) Yes b) no c)sometimes
Q8- do you feel anxious in new situations?
a) Yes b) no c)sometimes
Q9- do you have a hard time understanding your feelings?
a) Yes b) no c)sometimes
Q10-do you like staying by yourself?
b) Yes b) no c)sometimes
SECTION C – [visual/hearing disabilities]
Q1- do you feel handicapped due to your disability?
a) Yes b) no c)sometimes
Q2- does this disability affect you to do every day activities?
a) Yes b) no c)sometimes
Q3- are you good with social events?
a) Yes b) no c)sometimes
Q4- do you need to learn any other way to communicate?
a) Yes b) no c)sometimes
Q5- do you need help in doing activities?
a) Yes b) no c)sometimes
Q6- do you have problem making friends?
a) Yes b) no c)sometimes
Q7- do you get anxious in new situations/places?
a) Yes b) no c)sometimes
Q8- do you need some extra help to understand any assignment?
a) Yes b) no c)sometimes
Q9- do you use any equipment that may help you hear better?
a) Yes b) no c)sometimes
Q10- have you ever thought of getting any surgery that may help
you?
a) Yes b) no c)sometimes