SURVEY QUESTIONS
Health survey questions:
Q1. On a scale of 1 to 10, how healthy do you consider yourself?
Q2. Do you currently suffer from any chronic diseases?
1. Yes
2. No
Q3. Do you have any hereditary conditions/diseases?
1. High blood pressure
2. Diabetes
3. Haemophilia
4. Thalassemia
5. Huntington
6. Other (Please specify)
Q4. 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
Q5. How often do you get a health check-up?
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
Q6. How would you evaluate your overall health? Would you say you are?
1. In good physical health (No illness or disabilities).
2. Mildly 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)
Q7. 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
Q8. In the past 24 hours, what different kinds of medications have you taken?
Q9. 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
Q10. 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
Q11. 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)
Q12. 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
Q13. Has any of your family members been dropped out of coverage after a diagnosis of
any illness?
1. Yes
2. No
Q14.: 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
CANCER RELATED
Q15. Do you think that public cancer education helps save lives?
1. Yes
2. No
Q16. Is cancer education reaching the people who need it most?
1. Yes
2. No
Q17. Do you think being overweight increases the risk of Breast Cancer
1. Highly
2. Fairly
3. No
Q18. Change in size and shape of the breast can be a sign or symptom of breast cancer?
1. Yes
2. No
Q19. High-fat diet increases the risk of breast cancer?
1. Highly
2. Fairly
3. No
Q20. Do you think Cervical Cancer is the most prevalent type of cancer among Indian
women?
1. Yes
2. No
Q21. Which among the mentioned risk factors are more likely the reason for Cervical
Cancer?
1. Marriage at an early age
2. Having multiple pregnancies
3. Using contraceptives Smoking
4. Having infections in cervix
5. Personal hygiene
6. Nutrition
Q22. Having somebody in your family with prostate cancer increases the chance of
getting prostate cancer?
1. Yes
2. No
Q23. Which among the mentioned risk factors are more likely the reason for Oral
Cancer?
1. Smoking
2. Alcohol
3. Chewing tobacco
4. Sedentary life style
5. Family history of cancer
6. Poor Oral hygiene
Q24. Which among the mentioned are signs/symptoms for Oral Cancer?
1. Knowledge of signs/Symptoms
2. Growth of abnormal tissue
3. Non-healing wound
4. White or red spot
5. Reduced mouth opening
6. Undue falling of teeth
7. Continuous pain in jaw
Q25. Which among the mentioned are the risk factors related to Lung Cancer?
1. Cigarette smoking
2. Past cancer treatment
3. Past history of cancer, for example head and neck
4. Air pollution
5. Close relative with lung cancer
Q25. Which among the mentioned could be the warning signs related to Lung Cancer?
1. Sudden Weight loss
2. Shortness of breath
3. Coughing up blood
4. Loss of appetite
5. High-pitched sound when breathing
6. Persistent tiredness
7. Painful cough
