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

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* 1. What is your current age (in years)?

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* 2. What is your biological sex?

Prefer not to answer

Male

Female

Other (please specify)

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* 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

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* 4. What is your current profession?

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* 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

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* 6. What is your marital Status?

Married

Divorced

Widowed

Never been married

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* 7. How many members live in your household?

1 (live alone)

more than 4

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* 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)

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* 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.)

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* 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)

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* 11. Do you or your spouse (if you are married) experience chronic pain? (either ongoing or chronic pain)

Self

Spouse

Both

Neither

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* 12. If yes, how are you or your spouse currently being treated for chronic pain?

No treatment

Medication

Not applicable

Other (please specify)

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* 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

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* 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

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* 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

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* 16. Have you or a member of your family ever tested positive for COVID?

Yes

Never did a test

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* 17. How many doses of the Covid-19 vaccine have you had?

3 or more

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* 18. Have you ever been tested positive for Covid-19 after you have been vaccinated?

Yes

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* 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

I need more

Other (please specify)

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* 20. Do you know how to access/order Covid-19 prevention kits/ supplies?

Yes

Other (please specify)

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* 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)

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* 22. In the past 24 hours, what different kinds of medications have you taken?

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* 23. How many medications have been prescribed by your physician that you have taken in the last 24 hours?

more than 4

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* 24. In the past year have you experienced discrimination or harassment because of your religion?

Yes

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* 25. Are you currently taking any of these medication?

Birth Control Medications

Hormone based medications

None

N/A

Other (please specify)

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* 26. Have you ever had any complications during pregnancy/during labor?

Yes

N/A

Other (please specify)

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* 27. How many kids do you have?

More than 3

N/A

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* 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)

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* 29. Are you in need of any immediate health assistance?

Yes

If yes, please specify

Muslim Health Assessment Survey

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* 1. What is your current age (in years)?

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* 2. What is your biological sex?

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* 3. What is your highest educational degree attained?

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* 4. What is your current profession?

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* 5. What is your average household income?

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* 6. What is your marital Status?

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* 7. How many members live in your household?

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* 8. How often do you get a health checkup?

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* 9. How would you evaluate your overall health. Would you say you are:

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* 10. Have you ever had, or do you currently have any of the following conditions (check all that apply)?

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* 11. Do you or your spouse (if you are married) experience chronic pain? (either ongoing or chronic pain)

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* 12. If yes, how are you or your spouse currently being treated for chronic pain?

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* 13. Are you a habitual user of alcohol, recreational drugs, or other substances? (use more than 4x a week)

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* 14. Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?

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* 15. Over the past 2 weeks, how often have you felt down, depressed, or hopeless?

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* 16. Have you or a member of your family ever tested positive for COVID?

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* 17. How many doses of the Covid-19 vaccine have you had?

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* 18. Have you ever been tested positive for Covid-19 after you have been vaccinated?

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* 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?

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* 20. Do you know how to access/order Covid-19 prevention kits/ supplies?

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* 21. Which health insurance coverage provider are you currently enrolled with?

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* 22. In the past 24 hours, what different kinds of medications have you taken?

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* 23. How many medications have been prescribed by your physician that you have taken in the last 24 hours?

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* 24. In the past year have you experienced discrimination or harassment because of your religion?

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* 25. Are you currently taking any of these medication?

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* 26. Have you ever had any complications during pregnancy/during labor?

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* 27. How many kids do you have?

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* 28. On how many of the last 7 days did you engage in moderate to strenuous exercise?

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* 29. Are you in need of any immediate health assistance?

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* 30. If you have any questions or concerns, please contact CAIR Oklahoma's health department: 404-974-5470