Muslim Health Assessment Survey
This survey will allow us to get a better understanding of the Muslim community’s practice patterns towards various clinical problems and diseases. Gathering this information will allow us to better assist and serve the community
1.
What is your current age (in years)?
2.
What is your biological sex?
Prefer not to answer
Male
Female
Other (please specify)
3.
What is your highest educational degree attained?
High school completion diploma
Associates degree
Bachelor's degree
Master's degree
PhD & Doctoral degree
Other professional degree (e.g. Juris Doctor)
Other: Please specify
4.
What is your current profession?
5.
What is your average household income?
Below $30,000
$30,000-$50,0000
$50,000-$70,000
$70,000-$100,000
Over $100,000
6.
What is your marital Status?
Married
Divorced
Widowed
Never been married
7.
How many members live in your household?
1 (live alone)
2
3
4
more than 4
8.
How often do you get a health checkup?
Once in 3 months
Once in 6 months
Once a year
Only when needed
Never get it done
Other (please specify)
9.
How would you evaluate your overall health. Would you say you are:
In good physical health.
(No significant illnesses or
disabilities. Only routine medical
care such as annual checkups required.)
Mildly physically impaired. (You have
only minor illnesses and/or
disabilities which might benefit
from medical treatment or
corrective measures.)
Moderately physically impaired.(You
have one or more diseases or
disabilities which are either
painful or which require
substantial medical treatment.)
Severely physically impaired. (You have
one or more illnesses or
disabilities which are either
severely painful or life
threatening, or which require
extensive medical treatment
Totally physically impaired. (Confined
to bed and requiring full-time
medical assistance or nursing care
to maintain vital bodily functions.)
10.
Have you ever had, or do you currently have any of the following conditions (check all that apply)?
Stroke
Heart Attack
High Blood Pressure
Diabetes (type 1)
Diabetes (type 2)
Cancer
Heart Disease
Lung disease
Other (please specify)
11.
Do you or your spouse (if you are married) experience chronic pain? (either ongoing or chronic pain)
Self
Spouse
Both
Neither
12.
If yes, how are you or your spouse currently being treated for chronic pain?
No treatment
Medication
Not applicable
Other (please specify)
13.
Are you a habitual user of alcohol, recreational drugs, or other substances? (use more than 4x a week)
Yes to both
Only drugs
Only alcohol
Neither
14.
Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Not at all
Several days
More days than not
Nearly everyday
15.
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
Not at all
Several days
More days than not
Nearly every day
16.
Have you or a member of your family ever tested positive for COVID?
Yes
No
Never did a test
17.
How many doses of the Covid-19 vaccine have you had?
0
1
2
3 or more
18.
Have you ever been tested positive for Covid-19 after you have been vaccinated?
Yes
No
19.
Do you currently have enough Covid-19 prevention kits/supplies? e.g. masks, test kits, hand sanitizers etc. for all members of your household?
Yes
No
I need more
Other (please specify)
20.
Do you know how to access/order Covid-19 prevention kits/ supplies?
Yes
No
Other (please specify)
21.
Which health insurance coverage provider are you currently enrolled with?
Medicaid
Medicare
Affordable Act
Uninsured
Private health insurance (Blue Cross, Aetna etc.)
Other (please specify)
22.
In the past 24 hours, what different kinds of medications have you taken?
23.
How many medications have been prescribed by your physician that you have taken in the last 24 hours?
0
1
2
3
4
more than 4
24.
In the past year have you experienced discrimination or harassment because of your religion?
Yes
No
25.
Are you currently taking any of these medication?
Birth Control Medications
Hormone based medications
None
N/A
Other (please specify)
26.
Have you ever had any complications during pregnancy/during labor?
Yes
No
N/A
Other (please specify)
27.
How many kids do you have?
0
1
2
3
More than 3
N/A
28.
On how many of the last 7 days did you engage in moderate to strenuous exercise?
0 day
1 day
2 days
3-5 days
Other (please specify)
29.
Are you in need of any immediate health assistance?
Yes
No
If yes, please specify
30.
If you have any questions or concerns, please contact CAIR Oklahoma's health department: 404-974-5470
