Dechapattanayanukul
Student’s Project Study
M- 2/1, 3/1 ( Science and English Integration)
Academic Year 2010-2011
Survey Instrument and Consent form
Please allow the adult ( 18 or older) with the most recent past birthday to complete the survey for your household.
Instruction: Check the blank space inside the parentheses for your answer.
1.What common illness your family had experienced for the past 9months ( January to October) this year?
a. ( _ ) Colds f. ( _ ) Mumps k. ( _ ) nausea ( related to other illnesses)
b. ( _ ) Influenza(head ache) g. ( _ ) Sore eyes l. ( _ ) ear infection
c. ( _ ) Toothache h. ( _ ) Measles m. ( _ ) other please specify ________________________
d. ( _ ) Constipation i. ( _ ) Allergy
e. ( _ ) Diarrhea j. ( _ ) head ache
2.Synptoms
a.( ) high temperature of body( fever) f.( ) frequent urination l. ( ) perspire much
b.( ) rashes g.( ) abnormal bowel movement m ( ) cold
c.( ) change color of skin h.( ) head ache n. ( ) pain in some body parts
d.( ) lost of appetite j. ( ) nausea o. ( ). itchiness
e.( ) lost of weight k ( ) vomit p. ( ) other specify _______________
3. For how many days ?
Ans. a. For _____ days. b. ____ weeks
4.Possible source of infection or diseases ?
a. ( ) contaminated food.
b. ( ) contaminated water
c. ( ) acquired from infected person
d. ( ) insect bites
e. ( ) from public utensils (fork and spoon, plates, drinking glass, and nail cleaning materials like nail
cutter and scissor )
f. ( ) other specify the method _________________________________________________________.
5.Applied remedy method.
5.a. __________________ a.( ) applies herbal medicine
Name of ailment b.( ) seek doctor’s help
c ( ) other method , specify_____________________________________
_______________________________________________________
. 5.b.___________________ a. ( ) applied herbal medicine
Name of ailment b. ( ) seek doctor’s help
c. ( ) other method , specify ___________________________________.
_______________________________________________________
6. Result after remedy was applied. Patient became! a. ( ) better b. ( ) worst
7. Comment after remedy was applied .a.( ) good b.( ) bad c.( ) not sure
8. Name of medicine used __________________
a. ( ) modern synthetic medicine ( antibiotic, paracetamol, etc __________)
b. ( ) traditional herbal medicine. __________________________________.
9. To prevent the spread of diseases or its occurrence, what must be done?
a. ( ) avoid big crowded places c.( ) take more vitamins,vegetable, rest and exercise.
b. ( ) general cleaning of surrounding.
10. Personal Suggestion about ailment’s awareness and remedies.
Signature:
__________________________
___________________________
Name of Family ( Father or Mother )
No comments:
Post a Comment