Name (optional): ____________________________ Age: _____________ Sex: ________

Affiliation/Name of organization: ______________________ Educational Attainment: ________

General Instruction: Please read carefully and check the corresponding box that represent your
answer. Check one box per item only.

Topics Completely Partially Don’t Know

Understood Understood
MENTAL & EMOTIONAL HEALTH
1.
2.
3.
4.
5.
FAMILY LIVING
1.
2.
3.
4.
5.
GROWTH & DEVELOPMENT
1.
2.
3.
4.
5.
NUTRITION
1.
2.
3.
4.
5.
PERSONAL HEALTH
1.
2.
3.
4.
5.
ALCOHOL, TOBACCO, OTHER DRUGS
1.
2.
3.
4.
5.
COMMUNICABLE AND CHRONIC DISEASE
1.
 2.
3.
4.
5.
INJURY PREVENTION AND SAFETY
1.
2.
3.
4.
5.
CONSUMER AND COMMUNITY HEALTH
1.
2.
3.
4.
5.
ENVIRONMENTAL HEALTH
1.
2.
3.
4.
5.

Qualitative questions:
1.
2.
3.