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COPY OF CONSENT FORM

I Ms./Mr. …………………………………………………… voluntarily willing to

participate in the study conducted by Ms. Anjali Bagh, Ms. Kalika Bhawre and Mr. Sandeep

Uikey of IVth year B.Sc. Nursing titled “ A Study to Assess Knowledge Regarding Life Style

Diseases & their Prevention Among Under-Graduate Students in Selected Colleges in

Jabalpur (MP)” I will also co-operate with the researcher in providing necessary information. I

was explained that the information provided would be kept in confidential and used only for

above mentioned study purpose,

Signature of the Participant


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QUESTIONNAIRE

Section A
DEMOGRAPHIC DATA
(1). Age in years-
a. 19-21 yeas
b. 22-24 years
c. 25-27 years
d. More than 28 years

(2).Gender-
a. Male
b. Female

(3). Religion-
a. Hindu
b. Muslim
c. Christian
d. Shikh
e. Others

(4). Education-
a. 12th
b. Undergraduate
c. Others (Specify ………………..)
(5) Type of family-
a. Nuclear
b. Joint
c. Extended

(6) Type of residential area-


a. Rural
b. Urban

(7). Family income-


a. Less than Rs. 5000/-
b. Rs. 5001/- - Rs. 10,000/-
c. Rs. 10,001/- - Rs. 15,000/-
d. More than Rs. 15000/-

(8) Are you working anywhere to earn money?


a. Yes
b. No.
If yes then specify……………..

(9). Do your parents are having any Life Style Diseases like Diabetes
Mellitus, HTN,CAD, Cancer etc.
a. Yes
b. No
If yes then specify………………
Section - B
1. Disease occur because of changes in Life Style Disease pattern is called-
a. Acute disease b) Life Style Disease c) Chronic disease d) None of these above

2. Which disease is called as Life Style Disease-


a. Hypertension b) Diabetes Mellitus c) Cancer d) All of these above

3. What are the basic causes of Life Style Disease occurrence?


a. Smoking & alcohol
b. Improper diet
c. Change in normal behavior patters
d. Al of these above

4. How to maintain a healthy Life Style Disease-


a. Diet & exercise
b. Avoid smoking & alcohol
c. Proper rest
d. All of these above

5. Increase level of glucose in blood is called as -


a. Hyper tension
b. Diabetes Mellitus
c. Coronary Artery Disease
d. Cancer

6. What is the reason of Diabetes Mellitus ?


a. Family history of Diabetes Mellitus
b. Age
c. Obesity
d. All of these above

7. What are the basic sign & symptoms of Diabetes Mellitus?


a. Increase thrust
b. Increase appetite
c. Increase urine output
d. All of these above

8. How to prevent Diabetes Mellitus?


a. Healthy diet & exercise
b. Smoking
c. Alcohol
d. Bed rest

9. Which kind of diet is not given to diabetic patient?


a. High calorie diet
b. Low calorie diet
c. Fiber food
d. Sugar diet

10.What do you mean by hypertension ?


a. Increase heart rate
b. Decrease heart rate
c. Weakness
d. Obesity

11.What are the causes of Hypertension?


a. Excessive Stress
b. Obesity
c. Heredity
d. All of these above
12.What are the symptoms seen in Hypertension?
a. Increase heart rate
b. Decrease heart rate
c. Weight loss
d. Weakness

13. The normal value of blood pressure is -


a. 100/60 mm Hg
b. 120/80 mm Hg
c. 130/100 mm Hg
d. 140/90 mm Hg

14.What type of diet we should give to Hypertension patient?


a. High calorie diet
b. Low salt diet
c. Spicy food
d. Fatty food

15.How can we prevent Hypertension?


a. Low sodium diet
b. Avoid bad Life Style Disease
c. Regular exercise
d. All of these

16.Excessive fat deposition in body is called-


a. Obesity b. Hypertension c. Coronary Artery disease d. Cancer
17.What do you mean by Coronary Artery Disease?
a. Fat deposition in blood vessel
b. Increased heart rate
c. Swelling in whole body
d. Clot formation in whole body

18.What are the causes of Coronary Artery Disease?


a. Low cholesterol diet
b. High fatty diet
c. Low salt diet
d. High salt diet

19.What are the symptoms of Coronary Artery Disease?


a. Chest pain
b. Hypertension
c. Swelling in body
d. Obesity

20.Which type of diet should not give to patient with Coronary Artery Disease?
a. Spicy food
b. High fat diet
c. Junk / street food
d. All of these above

21.What do you mean by Cancer?


a. Enlargement of cells
b. Abnormal growth of cell
c. Pain
d. Weakness
22.Cancer occur in mouth is called?
a. Oral Cancer
b. Cervix Cancer
c. Breast Cancer
d. Lung Cancer

23.What are the causes of Cancer?


a. Smoking & alcohol
b. Tobacco
c. Sun exposure
d. All of these above

24.What are symptoms of Cancer?


a. Weight loss
b. Pain
c. Weakness
d. All of these above

25.How to prevent Cancer?


a. Avoid smoking & alcohol
b. Avoid radiation contact
c. Daily exercise
d. All of these above

26.What type of treatment is recommended for Cancer patient-


a. Chemotherapy
b. Surgical therapy
c. Radiation therapy
d. All of these above
Answer Key

Section B

Question No. Ans. Code


1 B
2 D
3 D
4 D
5 B
6 D
7 D
8 A
9 A
10 A
11 D
12 A
13 B
14 B
15 D
16 C
17 A
18 B
19 A
20 D
21 B
22 A
23 D
24 D
25 D
26 D
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¼c½ 120/80 feeh ikjk
¼l½ 130/100 fe eh ikjk
¼M½ 140/90 feeh ikjk

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17- /keuh dh chekjh ls vki D;k le>rs gS


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