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Assignment # 2
Managing
Customer
Relationships
Prepare two questionnaire’s samples.
Sana Ashraf
BBA level 5
Batch # 1
Date: 11/03/2017
Faculty: Mrs Asra Hameed
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Questionnaire sample #1
Original Date:
Dates Revised:
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.
Name (Last, First, M.I.): M F DOB:
Marital status: Single Partnered Married Separated Divorced Widowed
Previous or referring doctor: Date of last physical exam:
PERSONAL HEALTH HISTORY
Childhood illness: Measles Mumps Rubella Chickenpox Rheumatic Fever Polio
Immunizations and Tetanus Pneumonia
dates:
Hepatitis Chickenpox
Influenza MMR Measles, Mumps, Rubella
List any medical problems that other doctors have diagnosed
Surgeries
Year Reason Hospital
Other hospitalizations
Year Reason Hospital
Have you ever had a blood transfusion? Yes No
Please turn to next page
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug Strength Frequency Taken
Allergies to medications
Name the Drug Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Exercise Sedentary (No exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet Are you dieting? Yes No
If yes, are you on a physician prescribed medical diet? Yes No
# of meals you eat in an average day?
Rank salt intake Hi Med Low
Rank fat intake Hi Med Low
Caffeine None Coffee Tea Cola
# of cups/cans per day?
Alcohol Do you drink alcohol? Yes No
If yes, what kind?
How many drinks per week?
Are you concerned about the amount you drink? Yes No
Have you considered stopping? Yes No
Have you ever experienced blackouts? Yes No
Are you prone to “binge” drinking? Yes No
Do you drive after drinking? Yes No
Tobacco Do you use tobacco? Yes No
Cigarettes – pks./day Chew - #/day Pipe - #/day Cigars - #/day
# of years Or year quit
Drugs Do you currently use recreational or street drugs? Yes No
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Have you ever given yourself street drugs with a needle? Yes No
Sex Are you sexually active? Yes No
If yes, are you trying for a pregnancy? Yes No
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort with intercourse? Yes No
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health
problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would
you like to speak with your provider about your risk of this illness? Yes No
Personal Do you live alone? Yes No
Safety
Do you have frequent falls? Yes No
Do you have vision or hearing loss? Yes No
Do you have an Advance Directive and/or Living Will? Yes No
Would you like information on the preparation of these? Yes No
Physical and/or mental abuse have also become major public health issues in this country. This often takes
the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this
issue with your provider? Yes No
FAMILY HEALTH HISTORY
AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS
Children M
Father
F
M
Mother
F
Sibling M M
F F
M M
F F
M Grandmother
F Maternal
M Grandfather
F Maternal
M Grandmother
F Paternal
M Grandfather
F Paternal
MENTAL HEALTH
Is stress a major problem for you? Yes No
Do you feel depressed? Yes No
Do you panic when stressed? Yes No
Do you have problems with eating or your appetite? Yes No
Do you cry frequently? Yes No
Have you ever attempted suicide? Yes No
Have you ever seriously thought about hurting yourself? Yes No
Do you have trouble sleeping? Yes No
Have you ever been to a counselor? Yes No
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WOMEN ONLY
Age at onset of menstruation:
Date of last menstruation:
Period every days
Heavy periods, irregularity, spotting, pain, or discharge? Yes No
Number of pregnancies Number of live births
Are you pregnant or breastfeeding? Yes No
Have you had a D&C, hysterectomy, or Cesarean? Yes No
Any urinary tract, bladder, or kidney infections within the last year? Yes No
Any blood in your urine? Yes No
Any problems with control of urination? Yes No
Any hot flashes or sweating at night? Yes No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Yes No
Experienced any recent breast tenderness, lumps, or nipple discharge? Yes No
Date of last pap and rectal exam?
MEN ONLY
Do you usually get up to urinate during the night? Yes No
If yes, # of times
Do you feel pain or burning with urination? Yes No
Any blood in your urine? Yes No
Do you feel burning discharge from penis? Yes No
Has the force of your urination decreased? Yes No
Have you had any kidney, bladder, or prostate infections within the last 12 months? Yes No
Do you have any problems emptying your bladder completely? Yes No
Any difficulty with erection or ejaculation? Yes No
Any testicle pain or swelling? Yes No
Date of last prostate and rectal exam?
OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin Chest/Heart Recent changes in:
Head/Neck Back Weight
Ears Intestinal Energy level
Nose Bladder Ability to sleep
Throat Bowel Other pain/discomfort:
Lungs Circulation
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Questionnaire sample # 2
Club Questionnaire survey
At this club everyone is welcome regardless of their ability or where they come from. It’s important to have fun and
that its members feel valued and a part of the club. Its requirement is those people who are good at sports and who
behave respectfully to others – both on and off the field.
The Committee would like to thank all members and their families and our other volunteers for their contribution over
the past season. It is important to us that the club is welcoming and safe and that everyone gets a fair go.
To help the club prepare for its next season the club is keen to get your feedback about your experiences with club.
You do not need to provide your name as individual responses are not reported on.
To help the club improve its services it would like you to fill out this short survey.
1. Why did you join our club?
To be with friends To have fun To be involved with your
community
To be part of a competition To keep fit
2. Do you and your family feel welcome at our club?
Yes No
3. Are our facilities clean and tidy?
Yes No
4. Do you know that our club has flexible fee payment options and a uniform and
equipment loan scheme?
Yes No
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5. Do you know that our club may be able to help out with transport to games?
Yes No
6. Have the rules of the game and our club been explained to you?
Yes No
7. Are you aware of our Member Protection policy and Codes of Conduct?
Yes No
8. Are you aware of our complaints policy?
Yes No
9. Do you know who to contact if you have any issues or concerns?
Yes No
10. Do you think the club has got the right balance with providing opportunities to:
Be with friends and family Yes Somewhat No
Keep fit Yes Somewhat No
Have fun Yes Somewhat No
Play competitively Yes Somewhat No
Be part of the community Yes Somewhat No
11. Is participation seen to be as important as competing to win in our club?
Yes No
12. Were you and your partner or family invited to all social activities?
Yes No
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13. Did you feel welcome to attend all of the club functions/social activities?
Yes No
14. Did social activities take consideration of cultural differences (for example serving
Halal sausages)?
Yes No
15. Did club photos and other promotional material reflect the membership of our
club (for example
Yes No
16. Were our facilities clean and tidy?
Yes No
17. Could you access showers and change rooms when you needed them (for example,
after your game)?
Yes No
18. Was your privacy respected in the showers and change rooms?
Yes No
19. Did our club support your participation with flexible fee payment options
Yes Not applicable to me as I didn’t need this
assistance
No
20. If you didn’t understand the rules of our sport did someone explain these to you?
Yes No
21. If you were a new member, were you offered a ‘buddy’ to help you feel part of the
team?
Yes No
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22. If not, would having a buddy have helped you?
Yes No
23. Were you encouraged to apply for a position on the Committee or as a coach or
umpire?
Yes No
24. Did you feel uncomfortable about the treatment of women/girls around the club at
any time throughout the past season?
Yes No
25. Are women and girls encouraged to be involved in all club-related activities,
whether as players, coaches, umpires, spectators, members of committees?
Yes No
26. Would you agree that the Club welcomes or involves people from diverse cultural
backgrounds?
Yes No
27. Do you think our Club is broadly representative of the surrounding community (in
other words, have people from all of the backgrounds that make up our
neighbourhoods)?
Yes No
28. Were coaches and others in positions of leadership good role models?
Yes No
29. If there was any inappropriate behaviour did our club take the matter seriously
and act quickly?
Yes Not applicable
No
Thank you for completing this survey. The club will share the collated survey results with all
members.
