LOCATION Where are you located: Please Select One: Port Moresby Mt. Hagen Kokopo Lae PERSONAL DETAILS Your province of origin: Please Select One: AROB Central Chimbu East New Britain East Sepik Eastern Highlands Enga Gulf Hela Jiwaka Madang Manus Milne Bay Morobe NCD New Ireland Oro (Northern) Southern Highlands West New Britain West Sepik Western Highlands Western Your age group: Please Select One: 12 - 17 18 - 24 25 - 34 35 - 46 45 - 64 65 - 74 75+ Are you a Parent? Please Select One: Yes No If you answered Yes, how many Children do you have? Please Select One: 1 2 3 4 5+ Gender: Please Select One: Female Male Occupation: Please Select One: Full-time employee Part-time employee Shift worker Student - primary (1-6) Student - lower secondary (7-10) Student - upper secondary (11-12) Student - university, college, tertiary institute PERSONAL HISTORY 1. I smoke cigarettes/tobacco: Never Occasionally Frequently 2. I drink alcohol (any form of alcohol): Never Occasionally Frequently 3. I drink Coca-Cola and other soft drinks: Never Occasionally Frequently 4. I chew betelnut: Never Occasionally Frequently 5. I eat foods that are high in salt, sugar and fat: Never Occasionally Frequently 6. I eat fruits and vegetables: Never Occasionally Frequently 7. I drink water: Never Occasionally Frequently 8. I exercise: Never Occasionally Frequently 9. Have you being diagnosed with any heart issues in the past? Yes No 10. Have you had any heart surgeries in the past? Yes No 11. I sleep 7-8 hours at night: Never Occasionally Frequently 12. I am under stress: Never Frequently Occasionally FAMILY HISTORY 1. Does anyone in your family (who is living) have heart disease or any other heart related issues? Yes No 2. If yes, what is their age range? Under 12 12 - 17 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75+ 3. Has anyone in your family passed away from heart disease? Yes No 4. If yes, what was their age range when they passed away? Under 12 12 - 17 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75+ PHYSICAL ASSESSMENT 1. Do you ever experience chest pain? Yes No 2. Do you ever have a hard time catching your breath? Yes No 3. Do you ever feel like you don't have energy, are lethargic or fatigued? Yes No 4. Do you ever feel your heart pounding or racing? Yes No 5. Do you ever have swelling in your legs and feet? Yes No 6. Do you ever have wounds, especially on your feet and buttocks? Yes No 7. Does it usually take long for a sore or wound to heal? Yes No Thank you for supporting cardiac health awareness!
