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Community Primary Health Care & Environmental Health Survey

Community Primary Health Care & Environmental Health Survey

Purpose:

This survey is designed to gather anonymized statistical data on health conditions, environmental exposure, and access to healthcare services in Umbilo and surrounding areas. The information collected will support community primary health care planning, prevention strategies, and service delivery by APEX Practice.

Important Note:

All information is confidential and will be used for statistical and public health purposes only.

Monthly Update:
Please return monthly to complete the form. This will allow for accurate statistics and allow us to escalate where required.

Your Name prefix, Mr or Mrs?

Community Primary Health Care & Environmental Health Survey

Section A: Demographic Information

Your name & Surname *

Cellphone Number *

Your E-mail

1. Age Range *

Under 5 years

5–12 years

13–17 years

18–25 years

26–35 years

36–45 years

46–55 years

56–65 years

over 65 years

2. Sex *

Male

Female

3. Area of Residence *

Umbilo

Carrington Heights

Congella

Glenwood

Clairwood

Manor Gardens

Cato manor

Berea

Rossburgh

Seaview

Bellair

Hillary

Mount Vernon

Malvern

Queensburgh

Northdene

Mosely

Montclair

Woodlands

Woodhaven

Yellowwood Park

Grosvenor

Wentworth

Brighton Beach

Treasure Beach

Ocean View

Fynnlands

☐ Other (please specify below):

If other selected above, please specifiy area

4. Length of time living in this area: *

Less than 1 year

1–5 years

6–10 years

More than 10 years

Section B: General Health Status

5. How would you rate your overall health? *

Excellent

Good

Fair

Poor

6. Do you currently suffer from any chronic medical conditions? (Tick all that apply) *

Asthma

Hypertension (High blood pressure)

Diabetes

Heart disease

Chronic lung disease (e.g. COPD)

Tuberculosis (current or past)

HIV

Allergies

☐ Other (please specify below):

If other selected above, please specifiy area

7. Have you experienced any of the following symptoms in the past 6 months? (Tick all that apply) *

Shortness of breath

Tightness in the chest

Persistent cough

Wheezing

Frequent headaches

Fatigue or weakness

Dizziness

None of the above

Section C: Respiratory & Breathing Health

8. Do you experience difficulty in breathing? *

Yes

9. If yes, how often does this occur?

Daily

Weekly

Occasionally

Only during illness

10. At what times is breathing difficulty most noticeable? (Tick all that apply) *

Early morning

Daytime

Evening

Night

During physical activity

I am not experiencing difficulty with breathing

11. Have you been diagnosed with asthma by a healthcare professional? *

Yes

12. If asthmatic, do you currently use any of the following? (Tick all that apply) *

Inhaler (reliever)

Inhaler (preventer)

Nebuliser

Other treatment

Not receiving treatment

13. Have you noticed worsening of breathing symptoms in the past year? *

Yes

Unsure

Section D: Environmental & Pollution Exposure

14. Do you believe environmental pollution affects your health in your area? *

Yes

Unsure

15. Which of the following environmental factors are present near your home? (Tick all that apply) *

Industrial fumes or smoke

Heavy traffic pollution

Burning of waste

Dust or construction activity

Strong chemical or sewage smells

None of the above

16. Have you noticed abnormal levels of air pollution recently? *

Yes

Unsure

17. If yes, what symptoms have you experienced during these periods? (Tick all that apply)

Breathing difficulty

Chest tightness

Eye or throat irritation

Headaches

Nausea

Section E: Blood Pressure & Cardiovascular Health

18. Have you ever had your blood pressure checked? *

Yes

19. If yes, when was your most recent blood pressure check?

Within the last 6 months

6–12 months ago

More than 1 year ago

20. Have you ever been told you have high blood pressure? *

Yes

Unsure

21. Are you currently receiving treatment or medication for blood pressure? *

Yes

Section F: Access to Healthcare & Treatment

22. Are you currently receiving medical treatment for any condition? *

Yes

23. If yes, where do you usually receive medical care?

Public clinic

Public hospital

Private doctor

Pharmacy

Traditional healer

24. Do you take any long-term medication? *

Yes

25. Have you experienced difficulty accessing healthcare services? *

Yes

26. If yes, what are the main challenges? (Tick all that apply)

Cost

Distance

Long waiting times

Lack of transport

Limited clinic hours

Section G: Community Health Needs

27. What health services do you feel are most needed in your community? (Tick all that apply) *

General primary healthcare

Respiratory care

Chronic disease management

Environmental health monitoring

Health education and screenings

28. Would you be willing to participate in free community health screenings if offered? *

Yes

(*) Required fields

APEX Practice
Durban, KZN 4000
South Africa

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