Health Status Questionnaire for Street Vendors

Section 1: Sociodemographic Profile

Name: ___________________ Age: ______ Vending Location: ________________
Gender: [ ] Male [ ] Female

1.1 What is the highest level of education you have attained?

[ ] No education [ ] Primary [ ] Secondary [ ] Vocational [ ] Tertiary [ ] Others________
1.2 Marital status
[ ] Single [ ] Married [ ]co-habiting [ ] Separated [ ] Divorced [ ] Widowed
1.3 What religious group do you belong to
[ ] Christian [ ] Muslim [ ] Protestant [ ] Others________
1.4 Which ethnic group do you belong to?
[ ] Visayan [ ] Zamboangueno [ ] Tausug [ ] Badjao [ ] Yakan [ ] Subanens [ ] Others ___
1.5 How much profit do you earn weekly? _______________
1.6 Where do you live? ___________________________________________
1.7 Do you have another job/vocation aside hawking?
[ ] Yes [ ] No If yes please state___________________
1.8 How much do you earn in a day? _______________
1.9 Are you registered in insurance programs?
[ ] No
[ ] Yes. Please select all that applies: [ ] SSS [ ] Philhealth [ ] Pag-ibig
1.10 What commodities are you selling/offering?
[ ] Ready-to-eat food
[ ] Candies and cigarettes
[ ] Services
[ ] Fruits
[ ] Merchandise

Section 2: Physical health

2.1 What symptoms did you experience in the past 30 days?
2.2 What symptoms are you currently experiencing?
System Health Complaints Episode in the past 30 days Currently
General Once Twice Thrice >3x Yes No
o Body weakness
o Loss of appetite
o Irritability
o Fever
o Others:________
Neurologic o Seizure episode
o Tingling sensation
o Concentration difficulties
o Others:___________
Integumentary o Rash
o Itching
o Bruise
o Bite
o Cut
o Abrasion
o Cracked heels
o Others__________
Respiratory o Cough
o Colds
o DOB
o Others__________
Cardiovascular o Rapid heart beating
o Chest tightness
o Others__________
Gastrointestinal o Diarrhea
o Constipation
o Vomiting
o Bloody stool
o Abdominal pain
o Back pain
Musculoskeletal o Join pain
o Fracture
o Difficulty walking
o Difficulty running
o Difficulty lifting or carrying objectives
o Injuries from fall
 o Injuries from motor vehicular accidents
Others
2.3 Have you had to stay away from vending for a period of time because of any of the above complaints? [ ] Yes [ ] No

2.4 If yes how long did you stay away from work because of the diseases? In months_______
2.5 Which of the mentioned health conditions you mentioned kept you from hawking?______
2.6 Do you have any health problems before hawking? [ ] Yes [ ] No
If yes please state the disease___________
***for those who answered yes for question 9.
2.7 Did you have other health problems with your other job?
[ ] Yes [ ] No. If yes please state the disease___________
2.8 Current health problems (To be filled by the examiner)
Categories Result Remarks
Normal
Abnormal
Not Examined
General Appearance

Temp: ______ Wt: _______

PR: ________ Ht: _______
Vital Signs RR:________
BP:________

Normal
Abnormal
HEENT
Not Examined
Normal
Abnormal
Neck
Not Examined
Normal
Abnormal
Chest and Lungs
Not Examined
Normal
Abnormal
Cardiovascular
Not Examined
Normal
Abdomen Abnormal
Not Examined
Normal
Abnormal
Genitourinary
Not Examined
Normal
Abnormal
Rectal
Not Examined
Normal
Abnormal
Musculoskeletal
Not Examined
Normal
Abnormal
Lymph Nodes Not Examined

Normal
Abnormal
Extremities/Skin Not Examined

Normal
Abnormal
Neurological Not Examined

Normal
Abnormal
Other:__________ Not Examined

Clinical Impression

Section 3: Environmental Hazards

3.1 What health hazards are you usually exposed to while vending?
[ ] Road traffic accidents
[ ] Falls and injuries
[ ] Verbal abuse from [ ] customers [ ] colleagues [ ] authorities
[ ] Physical abuse-Violence from [ ] customers [ ] colleagues [ ] authorities
[ ] Car fumes and air pollution
[ ] Harsh weather
[ ] Others___________
3.2 Duration of exposure
How long have you been hawking? In months ___________________
How many hours do you hawk in a day? ___________________

Section 4: Health Behavior

4.1 What risk prevention strategies do you employ in the workplace?
[ ] Nothing  Answer only question 4.4
[ ] I wear personal protective equipment: [ ] long sleeves / additional clothing [ ] face mask [ ]goggles / eye wear [ ] caps / hats
[ ] I have been vaccinated against diseases  Answer question 4.2 and 4.4
[ ] I go for regular check up Answer 4.3, 4.4 and 4.5
I take [ ] herbs [ ] painkillers [ ] food supplement for prevention  Answer 4.4, 4.6, 4.7 and 4.8
[ ] Others______________
***Follow up questions for risk prevent strategies
4.2 Which vaccine did you receive?
[ ] Tetanus [ ] Flu [ ] Rabies [ ] Other___________
4.3 How often do you go for check-ups?
[ ] Daily [ ] Weekly [ ] Monthly [ ] Yearly [ ] Occasionally [ ] Other___________
4.4 What do you usually do when you feel sick?
[ ] Seek consult (please answer 4.5)
[ ] Take over-the-counter medications
[ ] Ignore
[ ] Others
4.5 Where do you usually go?
[ ] Private clinic [ ] Health center [ ] Hospital [ ] Traditional healers [ ] Others___________
4.6 How often do you take medicines (herbs, painkillers, supplements, etc) for prevention?
[ ] Daily [ ] Weekly [ ] Monthly [ ] Yearly [ ] Occasionally [ ] Other___________
4.7 Which medication are you taking? _________________________
4.8 Where do you get the medicine from?
[ ] Pharmacy [ ] Friends [ ] Family [ ] Herbal store [ ] Self preparation [ ] Other___________

Section 5: Mental Health

5.1 In your experience of your workplace, please indicate which of the following are high stress factors:
[ ] Disability discrimination
[ ] Violence and aggression
[ ] Job security
[ ] Lack of support from government and other groups
[ ] Poor working condition
[ ] Harassment
[ ] Others, pls specify:_____________
None A little Some Most All of
5.2 Kessler Psychological Distress Questionnaire of of the of the of the the time
the time time time
time
1. In the past four weeks, how often did you feel worn out for no real reason?
2. In the past 4 weeks, how often did you feel nervous?
3. In the past 4 weeks, how often did you feel so nervous that nothing could calm you
down?
4. In the past 4 weeks, how often did you feel hopeless?
5. In the past 4 weeks, how often did you feel restless or fidgety?
6. In the past 4 weeks, how often did you feel so restless you could not sit still?
7. In the past 4 weeks, how often did you feel depressed?
8. In the past 4 weeks, how often did you feel that everything was an effort?
9. In the past 4 weeks, how often did you feel so sad that nothing could cheer you
up?
10. In the past 4 weeks, how often did you feel worthless?
THANK YOU AND GOD BLESS!