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Shifa Tameer- e – Millat University, Islamabad

Shifa College of Nursing

Topic: Immunization

Submitted to: Muhammad hafiz Irfan

Submitted by: Group no. 1

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CONSENT FORM
We are students of BSN final year students of Shifa College of Nursing, Shifa Tamer-e-Milat
University, Islamabad. We came here for the project work of our subject named, Community
Health Nursing-III. Our goal is to conduct research on Parents knowledge about anemia and
spread awareness regarding the subject .Our study is completely hazardless & has approval from
a competent authority. To carry out our study, we will ask you some questions which will take
about 10-15 minutes. It is guaranteed that all the data provided by you will remain confidential &
in case of its utilization, your name will be replaced by codes. We assure you that this is a one-
time data collection, with no predictable harm. Data provided by you will help the community as
by assessing that data we’ll develop our plan of action to educate the students. There will be no
monetary or any other benefits will be given to participating individuals. Your participation in
this study is completely voluntary. If you have any questions you can ask & if you want to
participate in the study kindly sign below.

Agreement to participate:

I have read and understood the information provided in the form of study participants. I agree to
participate in this study realizing I can withdraw anytime.
Participant name:
Participant signature:
Date:

DEMOGRAPHIC DATA:

Name: Date of Birth:

Age: Gender:

Martial: Occupation:

a) Married
b) Single
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Questionnaire

1. Do you know what is anemia?

( )Yes ( ) No

‫کیا آپ جانتے ہیں کہ خون کی کمی کیا ہے؟‬.

‫( )ہاں ( )نہیں‬

2. Has your child been diagnosed with anemia before?

( ) Yes ( ) No

‫ کیا آپ کے بچے کو پہلے انیمیا کی تشخیص ہوئی ہے؟‬.2

‫( ) ہاں( ) نہیں‬

3. Has your child complained of fatigue, weakness, or lack of energy?

( ) Yes ( ) No

‫ یا توانائی کی کمی کی شکایت کی ہے؟‬،‫ کمزوری‬،‫ کیا آپ کے بچے نے تھکاوٹ‬.3

‫( ) ہاں ( )نہیں‬

4. Does your child appear pale?

( ) Yes ( ) No

‫ کیا آپ کا بچہ پیال نظر آتا ہے؟‬.4

‫( ) ہاں( ) نہیں‬

5. Has your child experienced dizziness or lightheadedness?

( ) Yes ( ) No

‫۔کیا آپ کے بچے کو چکر آنا یا سر کا درد ہوا ہے؟‬5

‫( ) ہاں ( )نہیں‬
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6. Does your child often have cold hands and feet?

( ) Yes ( ) No

‫ کیا آپ کے بچے کے اکثر ہاتھ پاؤں ٹھنڈے رہتے ہیں؟‬.6

‫( ) ہاں ( )نہیں‬

7. Does your child experience frequent headaches?

( ) Yes ( ) No

‫ کیا آپ کا بچہ اکثر سر درد کا تجربہ کرتا ہے؟‬.7

‫( ) ہاں( ) نہیں‬

8. Does your child eat red meat (beef, lamb, etc.) per week?

( ) Yes ( ) No

( ) ‫ہاں( ) نہیں‬

9. Does your child consume iron-rich foods like spinach, beans, lentils, and
fortified cereals oftenly?

( ) Yes ( ) No

( ) ‫ہاں( ) نہیں‬

10. Does your child consume vitamin C-rich foods (oranges, strawberries, broccoli,
etc.) along with iron-rich meals to enhance iron absorption?

( ) Yes ( ) No

‫ کیا آپ کا بچہ آئرن جذب کو بڑھانے کے لیے آئرن سے بھرپور کھانوں کے ساتھ وٹامن سی سے‬.10
‫ بروکولی وغیرہ) کھاتا ہے؟‬،‫ اسٹرابیری‬،‫بھرپور غذائیں (سنتری‬
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‫( ) ہاں( ) نہیں‬

11. Does your child drink cow's milk or formula?

( ) Yes ( ) No

‫۔کیا آپ کا بچہ گائے کا دودھ پیتا ہے یا فارموال؟‬11

‫( ) ہاں( ) نہیں‬

12. Is your child currently taking any iron supplements or medications?

( ) Yes ( ) No

‫۔کیا آپ کا بچہ فی الحال آئرن سپلیمنٹس یا دوائیں لے رہا ہے؟‬12

‫( ) ہاں( ) نہیں‬

13. Have you consulted a doctor regarding your child's symptoms?

( ) Yes ( ) No

‫ کیا آپ نے اپنے بچے کی عالمات کے بارے میں ڈاکٹر سے مشورہ کیا ہے؟‬.13
‫( ) ہاں( ) نہیں‬

14.Has anyone in your immediate family (parents, siblings) been diagnosed with
anemia?

( ) Yes ( ) No

‫ بہن بھائی) میں کسی کو خون کی کمی کی تشخیص ہوئی ہے؟‬،‫ کیا آپ کے قریبی خاندان (والدین‬.15
‫( ) ہاں ( )نہیں‬