SEVAK: HEALTH, DISEASE AND NUTRITIONAL SURVEY
I. Demographics:
1. Name: ___________________________________________________________________
2. Address: ____________________________________________________________________
3. Date of Birth ____________
M/D/YR
AGE ____ Mobile No__________ House No________
4. Total Number of family members in the house _________ # Adults _______ # Children______
5. Sex:
Female ______
Male _____
6. Marital Status:
a. Married
b. Divorced
c. Widowed
d. Separated
e. Never been married
7. Family Income level (per month):
a. < Rs 2,000
b. Rs 2,000 – 5,000
c. Rs 5,000 – 10,000
d. Rs 10,000 – 15,000
e. ≥ Rs 15,000
8. Employment Status: Are you currently:
a. Employed for wages
b. Self-employed
c. Farmer (if so, do you own land? Yes____ Work as contract work/laborer_____)
d. Homemaker
e. Student
f. Retired
g. Unable to work
9. Educational level:
What is the highest grade or year of school you completed?
a. Grades 1 through 7 (Primary)
b. Grades 8 through 10 (Secondary)
c. Grades 11 or 12 (Higher Secondary)
d. College 1 year to 2 years (Some college)
e. College 4 years or more (College graduate)
f.
Post graduate
g. No formal education
h. Technical education or Vocational training or more
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II. Personal History:
1. Do you have any Allergies? If yes, list
them__________________________________________
2. Smoking
a. Everyday
b. Some days
c. Not at all
3. Do you use: Chewing tobacco/Paan _____ Cigarettes ________ Bidis _________Smokeless
tobacco ___________ Hookah__________ Gutka_________Tobacco paste_______________
(Check all that apply)
4. On average, about how may cigarettes/bidis/Paan/Gutka/chewing tobacco/smokeless tobacco a
day do you use now?
Number _________
5. How long have you been using these tobacco products? ____________ Years ________
Months
6.. Do you know you can get lung or mouth cancer from smoking or chewing tobacco?
a. Yes __________ b. No____________
7. Drinking Alcohol:
Considering all types of alcoholic beverages, how many times during the past month did you have
5 or more drinks on occasion?
___None ____Once ___Twice ____3to5 times ____6 to 9 times ___10 or more times
8. How long have you been using alcoholic beverages? ____________ Years ________ Months
9. Drug Abuse: Have you ever consumed anything such as Aphim, Opium, Ganza or Chorus?
Yes____________ No__________
10. Diet: Are you a Vegetarian______________ Non-vegetarian_______________________
11. What type of food do you typically consume? (check all that apply)
____Home cooked ____Restaurant food ____Fast-food ____Snacks
Has the doctor told you to avoid sugar, salt, oil, etc (i.e., do you have any dietary restriction for
health reasons)? No ______ Yes _______ (If Yes, please specify: _______________________)
12. Dietary Habits
(For interviewers = N for never, S for sometimes, O for often, or A for always )
How often do you…
1) Choose a diet low in fat, saturated fat, and
cholesterol?
N
S
O
A
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2) Limit use of sugars, sodas, and sweets?
N
S
O
A
3) Eat 5-6 roti/ idli/ nan or 4 cups of rice per day
N
S
O
A
4) Eat 1-2 medium size fruits each day?
N
S
O
A
5) Eat 3-5 cups of cooked vegetables each day?
N
S
O
A
6) Eat 1-2 cups of milk, buttermilk, or curd
each day?
N
S
O
A
7) Eat 2-3 cups of dal, rajma, soyabean, and nuts
Or consume meat/fish/eggs each day?
N
S
O
A
8) Read labels to identify calories, nutrients, fats, and
sodium content in packaged food?
N
S
O
A
9) Eat breakfast?
N
S
O
A
13. Knowledge of Diseases. Which of the following do you think are risk factors for
diabetes? (Check all that apply)
____Being overweight
____Being over the age for 45
____Lack of exercise
____Having a baby weighing over 9lbs.
____Obesity
____Having a family member with diabetes
____Excessive fat or calorie intake
14. Which of the following do you think are risk factors for cardiovascular disease (heart
attack, stroke, etc.)? (Check all that apply)
____High cholesterol
____Obesity
____Getting older
____Heart disease among family members
____Diabetes
____Lack of exercise
____Eating high fat foods
____Smoking
____Being male
____ stress
____Menopause
III. FAMILY HISTORY:
Did any member of your family receive treatment (family history of illness) for the following?
Please do not include spouse and his/her family members
Condition
Brother
Sister
Father
Mother
(Grand parents/
Uncles, aunts,
etc)
Diabetes
Heart attacks before
age 50
High blood pressure
Stroke
Kidney dialysis
Cancer (please specify
what kind)
Jaundice
Arthritis
High Blood Cholesterol
Psychiatric Illness
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Did any member of your family receive treatment from traditional healers? Yes_______
No_______
Please check the type of doctors typically visited by your family for sickness:
a.
b.
c.
d.
Medical doctors (MBBS/MD)___________
Homeopathic doctors _________________
Ayurvedic doctors ____________________
Religious healers (Sadhus) _____________________
IV. MEDICAL HISTORY:
1. Did a doctor or a nurse ever examine you for any of the following conditions? Please answer
yes or no. (Read the choices)
YES
NO
Never Heard of
Disease
Don’t know/Not
sure
Refused
YES
NO
Never Heard of
Disease
Don’t know/Not
sure
Refused
High Blood Cholesterol (fatty
substance in blood)
Breast Cancer
Cervical Cancer
Intestine and anal canal
(Colo-rectal Cancer)
Incontinence or urine
retention (Prostate Cancer)
Diabetes
Heart Disease
High Blood Pressure
Psychiatric Illness
Arthritis
Tubeculosis
Kidney problems
Thyroid problems
Jaundice
Back ache
Anemia
Diabetes Questions:
1. Have you ever been told by a doctor that you have diabetes?
a. Yes
b. No
(If female) Told only during pregnancy? a. Yes
b. No
2. How old were you when you were told you have diabetes? ___________
3. How many years do you have diabetes _________.
4. Are you now taking insulin?
a. Yes
b. No
5. Are you taking diabetes pills? a. Yes
b. No
List the medications ____________________________________________________
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6. How often do you take your diabetes medications?
a. Regularly
b. Take them only when you need it
c. Take them only when you feel ill
7. Are you experiencing any side effects to the medications? No _____ Yes ____
(please specify ________________________________________)
8. About how often do you check your blood for glucose or sugar? Include times when
checked by a health professional:
a. ____ Every day
b. ____2-3 Times per week
c. ____2-3 Times per month
d. ____2-3 Times per year
e. Never
9. Are you taking any other medications besides your diabetes medications? No _____
Yes ____ (please list the reason ________________________________________)
10. Have you ever had any sores or irritations on your feet that took more than four
weeks to heal?
a. Yes
b. No
11. About how many times in the past 12 months have you seen a doctor, nurse, or other
health professional for your diabetes?
a. Number of times ________ b. None
12. Has a doctor ever told you that diabetes has affected your eyes or that you had poor
vision (retinopathy)?
a. Yes ______
b. No ______
13. Have you ever taken a course or class in how to manage your diabetes yourself?
a. Yes ______
b. No _____
14. Do you know anyone who can teach you how to manage your diabetes?
a. Yes ______ (specify_________________________) b. No ____
Blood Pressure
1. About how long has it been since you last had your blood pressure taken by a doctor,
nurse, or other health professional?
a. Within the past 6 months (1 to 6 months ago)
b. Within the past years (6-12 months ago)
c. Within the past 2 years (1 to 2 years ago)
d. Within the past 5 years (2 to 5 years ago)
e. 5 or more years ago
2. Have you ever been told by a doctor, nurse of other health professional that you have
high blood pressure?
a. Yes
b. No  In No, skip to question 4.
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3. If yes, are you taking any medication for your blood pressure ?
a. Yes _________ (Please list ______________________________)
b. No
4. Blood cholesterol is a fatty substance (makes the blood thick). Have you ever had
your blood cholesterol checked?
a. Yes ____Your cholesterol level is ____________
b. No
5. If yes, are you taking any medications for your blood cholesterol?
a. Yes ____(Please list ______________________________)
b. No ________
Village Information:
1. Do you have a toilet? Yes_______ No__________
2. Do you have a Chula? Gas _____ Kerosene ______ Stove _______ Firewood _____
3. Does your kitchen have ventilation to the outside (ex- window) Yes______ No_____
4. What kind of drinking water do you have?
Well ______ Village tank __________ Pond_______ Tube Well _________ Hand
Pump_________ Stand Pipe _________________ None______________
5. Do you have RO water or chlorinated water? Yes___________ No_______
MEASUREMENTS
HEIGHT: ____FT _____IN :
WEIGHT: ______ LBS :
B.M.I:
WAIST CIRCUMFERENCE: ____ IN : HIP CIRCUMFRENCE_____IN
PRESSURE: ________
: BLOOD
FBS (fasting blood sugar):_______mg%
VI. DIAGNOSIS:
VII. FOLLOW UP AND COMMENTS:
SIGNATURE:
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