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Social Determinants of Health
Social Determinants of Health
Email
(Required)
Age:
Sex:
Male
Female
Current Marital Status:
Single
Married
Divorced
Widowed
Nationality:
Current Employment Status:
(Required)
Employed full-time
Employed part-time
Unemployed
Retired
Student
What is Family Monthly Income:
(Required)
Below 1000
1000-5000
5000-10,000
Above 10,000
Are you currently worried about financial stability?
(Required)
Not worried
Worried about Loss of job
Worried about Rising costs of living
Worried about Health expenses
Have you faced barriers in accessing healthcare? (Select all that apply)
(Required)
No barriers
Cost
Transportation
Language
Cultural beliefs
Lack of available services
How far is the nearest healthcare facility from your residence?
(Required)
Less than 10 mins
10-20 mins
20- 45 mins
1 hour and more
How often do you visit a healthcare provider?
(Required)
monthly
3 months
6 months
1 year
Only when needed
How many family members do you currently live with?
(Required)
What is your living family structure? during last 12 months
(Required)
living with parents ( Father, mother)
living with partner ( wife, husband)
have kids
living alone
living with a friend
What is the type of mass gatherings event you attend?
(Required)
Religious
Entrainments
Social
Sport
What is the name of this event?
(Required)
Where is this event located?
(Required)
How long is this event by days ?
(Required)
What month is this event?
(Required)
Do you have any chronic diseases?
(Required)
No
DM
HTN
Asthma
Epilepsy
Chronic kidney disease
Chronic liver disease
Chronic heart disease
Cancer
Obesity
Others
How many medications do you take regularly for chronic diseases?
(Required)
Have you experienced any health symptoms/event during or 1 week post this event ?
(Required)
No
Fever
Sore throat
Fatigue
Vomiting or Nausea
Diarrhea
Abdominal pain
Burning or pain with urination
Shortness of breath
Muscle ache
Headache
Chest pain
Foot pain
Skin rash
Itching
Injury
Have you had a health check-up before attending this event?
(Required)
Yes
No
Are you a smoker ?
(Required)
Yes, currently smoker
ex-smoker
No
How do you rate your overall physical fitness before starting this event?
(Required)
Excellent
Good
fair
poor
Do you take breaks during the long walks in this event?
(Required)
Yes
Sometimes
No
Do you stay hydrated during the event ?
(Required)
Yes
Sometimes
No
Have you ever felt peer pressure to engage in risky activities (e.g., smoking, substance use)?
(Required)
Yes
No
Have you participated in any activities that involve excessive risk-taking during this Events ?
(Required)
Yes
No
Do you feel that this event environment encourages or discourages risky behaviors?
(Required)
Encourages
Discourages
Neutral
Do you use any substances (e.g., drugs, alcohol) during this event
(Required)
Yes
No
Over the last two weeks, you felt little interest or pleasure in doing things?
(Required)
Not at all
Several days
More than half the days
Nearly every day
Over the last two weeks, how often have you felt down, depressed, or hopeless?
(Required)
Not at all
Several days
More than half the days
Nearly every day
Have you ever experienced anxiety or panic attacks?
(Required)
Yes
No
How would you rate your overall health today?
(Required)
Excellent
Very good
Good
Fair
Poor
How satisfied are you with your social life?
(Required)
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Do you believe that your health affects your daily activities?
(Required)
Yes
No
Do you think you need accompanying assistance during this event ?
(Required)
Yes
No
Did you have anyone who cared and accompanied you on this vent?
(Required)
Yes
No
How often have you visited a healthcare facility during this event?
(Required)
Never
Once
2-3 times
More than 3 times
Do you know if health services during this event are available free of charge or paid?
(Required)
Free of charge
Paid
I don't know
Did you know the emergency number if you have a health issue?
(Required)
Yes
No
When you have the choice to ride the bus, train, or car, do you prefer to use it?
(Required)
Yes
No
If you prefer not to use public transportation, what are the reasons?
(Required)
Crowding
Cost
Lack of knowledge on how to use it
Fear of safety
Preference for walking
How would you rate your awareness of health risks associated with this event?
(Required)
Very high
High
Moderate
Low
Very low
Before attending this event did you receive information regarding health risks and safety measures?
(Required)
Yes
No
Have you encountered any communication barriers related to health information in this event?
(Required)
Yes
No