Create Survey | Samarppanam

1. Do you have high blood pressure?*

Yes No

1.1. How long have you had high blood pressure?*

1-2 years 6 months 6 months

1.2. How many years have you been undergoing treatment for it?*

3 years more 2 years 1 Year

1.3. Is your blood pressure currently normal?*

No Yes

1.4. When was the last time you checked your blood pressure?*

4 weeks ago 2 weeks ago 1 week ago

1.5. Do you occasionally stop taking your blood pressure medications?*

No Yes

1.6. Does anyone in your family have high blood pressure?*

No Yes

1.7. Which of the following is your blood pressure ?*

140/90 mmHg or More 120/80 mmHg or Lower 120-140 mmHg / 80-90 mmHg

2. Do you smoke?*

Yes No

2.1. How many years have you been smoking?*

More than 3 years 2-3 years 1 year

2.2. How many cigarettes/beedis/hookah sessions do you smoke in a day?*

10-20 5-10 2-5

2.3. Have you ever tried to quit smoking?*

No Yes

2.4. Have you experienced any of the following health issues related to smoking?*

Oral cancer Amputation of the leg Non-healing wounds on the legs Lung cancer Persistent cough

2.5. Do you experience pain in your legs while walking?*

No Yes

2.6. Which among the following do you use ?*

Hookah Cigarettes Beedis

3. Do you have high cholesterol?*

Yes No

3.1. How many years have you had high cholesterol?*

More than 3 years 2-3 years 1-2 years

3.2. Are you undergoing treatment for it?*

No Yes

3.3. Do you have high triglycerides?*

don't know Yes No

3.4. Does anyone in your family have high cholesterol?*

No don't know Yes

3.5. Is your good cholesterol (HDL) more than 35 mg/dL?*

No don't know Yes

3.6. Which of the following is your cholesterol level ?*

more 250 mg /dl less 200 mg/dl 200-250 mg/dl

4. Do you eat fast food / Fried foods on a regular basis?*

Yes No

4.1. If so, how many times a month?*

More than 8 times 5-8 times 2-3 times

4.2. Do you regularly consume meat?*

No Yes

4.3. On average, how many times a day?*

< 2 < 3 < 5

4.4. If not continuously, how many times a week?*

< 2 < 3 < 5

4.5. Do you regularly eat fish?*

No Yes

5. Do you eat more than 5 servings of fruit in a week?*

Yes No

6. Do you consume vegetables more than 5 times a week?*

No Yes

7. Do you exercise regularly?*

Yes No

7.1. On average, how many days a week do you exercise?*

3-5 times 2-3 times 1-2 times

7.2. On each occasion, how many minutes do you typically exercise?*

More than 10 Minutes 8 Minutes 5 Minutes

7.3. Do you walk as part of your exercise routine?*

No Yes

7.4. Do you prefer walking or running?*

Running Walking

7.5. Do you participate in sports or physical activities?*

Physical Activities Sports

7.6. How long have you maintained this exercise routine?*

1 year 3-8 Month 1Month

8. Do you consume Alcohol?*

Yes No

8.1. How many years have you been drinking?*

More than 3 years 2-3 years 1 Year

8.2. How many times a day do you drink?*

More than 4 Times 2-4 times 1-2 times

8.3. How many times a week do you drink?*

More than 4 Times 2-4 times 1-2 times

8.4. On average, how much do you drink in a day? (in milliliters)*

More than 10 6-8 3-5

8.5. What type of alcohol do you consume?*

Brandy Whisky Beer Wine Liquor

8.6. Do you feel the need to reduce your alcohol consumption?*

No Yes

8.7. Do you ever feel guilty because of your drinking?*

No Yes

8.8. Do you drink early in the morning?*

No Yes

8.9. Does anyone in your family drink alcohol?*

No Yes

9. Do you chew tobacco?*

Yes No

9.1. How long have you been chewing tobacco?*

5 years 2 years 1 year

9.2. How many times a day do you chew tobacco?*

More than 4 Times 2-4times 1-2times

9.3. How many times a week do you chew tobacco?*

More than 8 5-8 2-4

9.4. Do you use products like pan parag or hans?*

No Yes

9.5. Does anyone in your family chew tobacco?*

No Yes

9.6. Have you experienced any of the following issues related to tobacco chewing?*

Oral cancer Oral sores

10. Have you ever had a stroke?*

Yes No

10.1. Does anyone in your family have a history of stroke?*

Aunts/uncles Siblings Maternal uncle Mother Father

10.2. Was the stroke you had related to a brain hemorrhage?*

Don’t know No Yes

10.3. Was the stroke due to high blood pressure?*

Don’t know No Yes

10.4. Was it on the left side?*

No Yes

10.5. Was it on the right side?*

No Yes

10.6. Did you receive treatment from a hospital for this stroke?*

No Yes

10.7. How long did you wait at home before seeking treatment?*

1-2 hours Half an hour 5-10 minutes

10.8. Did you believe the stroke was due to low blood sugar?*

Don’t know No Yes

10.9. Did you think it was due to insufficient food intake?*

Don’t know No Yes

10.10. Did you receive treatment for blood clot dissolution?*

Don’t know No Yes

10.11. Did you receive treatment for removing blood clots by angiogram ?*

Don’t know No Yes

10.12. Are you aware of any treatments similar to these?*

Don’t know No Yes

10.13. After the stroke, do you take medications like aspirin or clopidogrel?*

Don’t know No Yes

10.14. Have you had recurrent strokes?*

No Yes

10.15. Have you ever stopped taking medications like aspirin or clopidogrel?*

No Yes

10.16. Have you ever experienced sudden difficulty in speaking? If so, how long ago?*

Weeks Months Days

10.17. Have you ever experienced sudden difficulty in walking? If so, how long ago?*

Months Weeks Days

10.18. How much time elapsed between these issues and your consultation with a doctor?*

Don’t know 10-15 minutes 2-3 minutes

10.19. Do you experience occasional chest pain?*

No Yes

10.20. Do you undergo physiotherapy?*

No Yes

10.21. Since the stroke, are you able to perform all tasks as before?*

No Yes

10.22. After the stroke, do you need minor assistance?*

No Yes

10.23. After the stroke, do you need full assistance for all tasks?*

No Yes

10.24. Were you able to return to your previous job?*

No Yes

10.25. Have you changed jobs due to your stroke ?*

No Yes

10.26. Are you able to work at all?*

No Yes

10.27. If you are a woman, can you perform household chores as before?*

No Yes

10.28. Can you manage small tasks?*

No Yes

10.29. Are you in a condition where you cannot perform any work?*

No Yes

10.30. Have you consulted a neurologist or physician and been treated ?*

No Yes

11. Has anyone in your family had a heart attack / Stroke?*

Yes No

11.1. Have you consulted a neurologist or cardiologist and been treated ?*

No Yes

12. Do you experience heartburn?*

Yes No

12.1. Have you consulted a gastroenterologist or cardiologist and been treated ?*

No Yes

13. Do you get chest pain while walking, climbing stairs, or when you are anxious ?*

Yes No

13.1. Have you consulted a cardiologist or physician and been treated ?*

No Yes

13.2. Does the chest pain improve when you rest or stop walking?*

no Yes

14. Do you have breathing difficulty ?*

Yes No

14.1. Do you experience shortness of breath while walking?*

No Yes

14.2. Do you experience shortness of breath while lying down*

No Yes

14.3. Have you consulted a physician or cardiologist and been treated ?*

No Yes

15. Have you had paralysis, a stroke, or a heart attack in the last year?*

Yes No

15.1. Have you consulted a neurologist or cardiologist and been treated ?*

No Yes

16. Do you have diabetes ?*

Yes No

16.1. How long have you had diabetes?*

No Yes

16.2. Do you only follow a dietary regimen for diabetes?*

no Yes

16.3. Do you use Ayurvedic medicine for diabetes?*

no Yes

16.4. Do you take oral medication for diabetes?*

no Yes

16.5. Do you use insulin injections?*

no Yes

16.6. Do you worry that taking diabetes medication might damage your kidneys?*

no Yes Yes

16.7. Do you use both oral medication and insulin?*

no Yes

16.8. Is your diabetes under control?----- PLUS/MINUS*

no Yes

16.9. How long has it been since you last checked your blood sugar levels?*

Months Weeks Days

16.10. What was the last recorded level of your blood sugar?*

HbA1c Postprandial Blood Sugar (PPBS) Fasting Blood Sugar (FBS)

16.11. Does your blood sugar fluctuate frequently?*

no Yes

16.12. Does anyone in your family have diabetes?*

no Yes

16.13. Has diabetes affected your kidneys?*

no Yes

16.14. Has diabetes affected your nerves?*

no Yes

16.15. Has diabetes affected your eyes?*

no Yes

16.16. Do you have non-healing wounds on your legs?*

no Yes

16.17. Have you had an amputation of your leg?*

no Yes

16.18. Which of the following is your blood sugar level?*

More than 150 mg/dl less 126 mg/dl 126-150 mg/dl

17. Has your body weight increased recently?*

Yes No

17.1. Do you find it difficult to tolerate cold temperatures?*

no Yes

17.2. Have you noticed any changes in your voice?*

no Yes

17.3. Do you experience fatigue?*

no Yes

17.4. Do you experience heavy menstrual bleeding?*

no Yes

17.5. Have you had a thyroid test?*

no Yes

17.6. Have you consulted a physician or endocrinologist and been treated ?*

No Yes

18. Do you have epilepsy or fits ?*

Yes No

18.1. Have you heard of a condition known as epilepsy ?*

no Yes

18.2. Do you believe it is a mental illness?*

no Yes

18.3. Do you believe it is a hereditary condition?*

no Yes

18.4. Do you think it is a communicable disease?*

no Yes

18.5. Do you believe it is a punishment for your ancestors’ sins?*

no Yes

18.6. Do you think epilepsy might prevent you from getting married?*

no Yes

18.7. Do you think a good marital relationship is possible for someone with epilepsy?*

no Yes

18.8. Do you think sexual relationships are possible for someone with epilepsy?*

no Yes

18.9. Do you think education is possible for someone with epilepsy?*

no Yes

18.10. Do you think employment is possible for someone with epilepsy*

no Yes

18.11. Do you think children born to someone with epilepsy will have disabilities?*

no Yes

18.12. Do you think society will isolate someone with epilepsy?*

no Yes

18.13. Are you aware of good treatments for epilepsy?*

no Yes

18.14. Do you think the treatment is effective?*

no Yes Yes

18.15. Do you believe Ayurveda is beneficial for epilepsy?*

no Yes

18.16. If you encounter someone with epilepsy, what would you do?*

18.17. Would you allow your child to play with a child who has epilepsy?*

no Yes

18.18. Are you aware of surgical options for epilepsy?*

no Yes

18.19. Have you consulted a neurologist or physician and been treated ?*

No Yes

19. Do you see Blood in your urine?*

Yes No

19.1. Is there any frothing of Urine?*

19.2. Have you consulted a physician or urologist and been treated?*

No Yes

20. Have you lost more than 5 kilograms in the past 6 months?*

Yes No

20.1. Have you consulted a physician or endocrinologist and been treated?*

No Yes

21. Do you have sputum that is mixed with blood ?*

Yes No

21.1. Have you consulted a physician or pulmonologist and been treated?*

No Yes

22. Do you notice blood in your stool*

Yes No

22.1. Have you consulted a gastroenterologist and been treated?*

No Yes

23. Do you have lumps or swelling in your neck or breast?*

Yes No

23.1. Have you consulted a surgeon and been treated?*

No Yes

23.2. Do these lumps or swellings recently increase in size ?*

no Yes

24. Does anyone in your family have a history of cancer?*

Yes No

24.1. Have you consulted a physician or oncologist (cancer specialist) and been screened?*

No Yes

25. Do you frequently experience abdominal pain?*

Yes No

25.1. Have you consulted a gastroenterologist and been treated?*

No Yes

26. Do you experience difficulty in swallowing?*

Yes No

26.1. Have you consulted a gastroenterologist and been treated?*

No Yes

27. Do you use any narcotic substances*

Yes no

27.1. How long have you been using them?*

5 year 2 year 1 year

27.2. Do you use them every day?*

27.3. Do you use cannabis (marijuana)?*

no Yes

27.4. Do you use sleeping pills?*

no Yes

27.5. Do you use painkillers?*

no Yes

27.6. Do you take medications intravenously (through an IV)?*

no Yes

27.7. Do you use any other narcotic drugs?*

no Yes Yes

27.8. Are you able to stop using these substances?*

no Yes

27.9. Do you experience any withdrawal symptoms when you stop?*

no

27.10. Have you ever gone for de-addiction treatment?*

no Yes

28. Do you experience palpitations?*

yes no

28.1. Have you consulted a physician or cardiologist and been treated?*

No Yes

29. Have you ever experienced sudden weakness in your limbs, difficulty in speaking, unsteadiness or weakness of your face?*

Yes no

29.1. Have you consulted a neurologist or physician and been treated ?*

No Yes

30. Do you experience any sudden loss of consciousness or fainting?*

Yes no

30.1. Have you consulted a neurologist or cardiologist and been treated?*

No Yes

31. Do you experience memory loss ?*

Yes no

31.1. Have you consulted a neurologist and been treated ?*

no Yes

31.2. Are you over 30 years old?*

no Yes

31.3. Do you have trouble finding words?*

no Yes

31.4. How long have you been experiencing memory loss?*

Weeks Months years

31.5. Has memory loss been occurring for more than 6 months ?*

no Yes

31.6. Does anyone in your family have a history of memory loss?*

no Yes

31.7. Do you find it difficult to perform tasks you used to do due to memory issues?*

no Yes

31.8. Do you need assistance with most activities?*

no Yes

32. Do you experience unexplained sadness ?*

Yes no

32.1. Have you consulted a psychiatrist and been treated?*

No Yes

33. Do you frequently experience headache ?*

Yes no

33.1. How long have you been experiencing headaches?*

Years Months Weeks

33.2. Do you experience nausea with your headaches?*

Yes no

33.3. Do your headaches disrupt your sleep at night?*

no Yes

33.4. Do you wake up with headaches in the morning?*

no no Yes

33.5. Do you have double vision when you have a headache?*

no Yes

33.6. Does the headache get worse when you walk?*

no Yes

33.7. Does your headache get worse when you cough or sneeze?*

no Yes

33.8. Have you consulted a neurologist or physician and been treated ?*

no Yes

34. Do you experience tremor or difficulty in walking ?*

yes no

34.1. Have you consulted a neurologist or orthopedist and been treated ?*

No Yes

34.2. Do you have tremors in your hands or legs?*

no Yes

34.3. When are the tremors most pronounced?*

night day

34.4. Is your walking speed slow?*

no Yes

34.5. Do you experience a risk of falling while walking?*

no Yes

34.6. Are the tremors localized to one side of your body?*

no Yes

34.7. Does anyone in your family have tremors?*

no Yes

34.8. At what age did the tremors begin?*

45-75 25-45 18-25

34.9. Are you receiving treatment for this condition?*

no Yes

35. Do you experience loss of appetite?*

Yes no

35.1. Have you consulted a gastroenterologist and been treated ?*

No Yes

36. Do you have non-healing wounds or sores?*

Yes no

36.1. Have you consulted a surgeon or skin specialist and been treated ?*

no Yes

37. Do you have skin discoloration, such as black patches or bleeding from the skin?*

Yes no

37.1. Have you consulted a skin specialist and been treated ?*

No Yes

38. Do you experience excessive menstrual bleeding?*

Yes no

38.1. Have you consulted a gynecologist and been treated ?*

No Yes

39. Do you have persistent cough ?*

Yes no

39.1. Have you consulted a physician or chest physician (pulmonologist) and been treated ?*

No Yes

40. Do you have froth in your urine ?*

Yes no

40.1. Have you consulted a physician or nephrologist and been treated ?*

No Yes

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