World Health Survey Template Page 4
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57.
1000. Respondent’s Socio Demographic Characteristics
Time Begin: __ __ : __ __
..
I would like to start by asking you some background questions before asking you questions on your health. This information is confidential and will only be
used for research purposes.
.
Q1000 What is your mother tongue?
1. Female
2. Male
Q1001 Record sex as observed
Q1002 How old are you? (Years)
If age is known:
_____________________
888. DK
Go to Q1004
.
Q1003 If you don't know/don’t want to tell me your age could you tell me the
1. 18-19
age range if I read the different options to you (choose what is most
2. 20-29
appropriate) ?
3. 30-39
4. 40-49
(READ THE OPTIONS TO THE RESPONDENT)
5. 50-59
6. 60-69
7. 70+
.
Q1004 Your weight in Kilos?
If weight is in
kilos:
_____________________
Go to Q1006
Q1005 Your weight in Pounds?
_____________________
Q1006 Your height in Centimeters
If height is in
centimeters:
_____________________
Go to Q1008
Q1007 Your height in Feet / Inches
_____________________
Q1008 What is your current marital status?
1. Never
2. Currently
3. Separated 4. Divorced 5. Widowed 6.Cohabiting
Married
Married
.
Q1009 What is the highest level of education that you have completed?
1. No formal schooling
2. Less than primary school
3. Primary school completed
4. Secondary school completed
5. High school (or equivalent) completed
6. College / pre-university / University completed
7. Post graduate degree completed
.
Q1010 How many years of school, including higher education have you
completed?
_____________________
WORLD HEALTH SURVEY - SOCIO DEMOGRAPHIC CHARACTERISTICS
1.1
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