Clinic Questionnaire for Be Positive
DEMOGRAPHICS
1. What are your initials ______
2. What is your date of Birth? (dd/mm/yy)______
3. What is your gender? ☐ Male ☐ Female
4. What is your country of birth? ______
5. How many years have you been in Australia? ______
6. What language do you speak primarily at home? ______
7. What is the postcode for where you currently live? ______
8. What is your highest level of education?
☐ Never attended school ☐ High school, up to year ______
☐ Primary school ☐ University
9. How fluently do you speak English?
☐ No English ☐ Basic ☐ Fluent
10. What is your visa status?
☐ Australian citizen ☐ Australian Permanent Resident ☐ Other______
PRACTICES
10. When you are feeling sick or unwell, who do you go to see first?
☐ Family Doctor ☐ Traditional practitioner (e.g. spiritual healer)
☐ Other: [Please specify]: ______
a) Do you see a family doctor for your health?
☐ Yes ☐ No
b) How often do you visit your family doctor per year?
☐ Never ☐ 1 visit/year ☐ 2-4 visits per year
☐ > 5 visits/year
11. Do you ever see a traditional practitioner or an alternative to the doctor for your health?
☐ Yes ☐ No
a) If yes, how often do you visit your traditional practitioner per year?
☐ Never ☐ 1 visit/year ☐ 2-4 visits per year
☐ > 5 visits/year
12. How do you get information about your health? (You can pick more than one answer)
☐ Family Doctor ☐ TV ☐ Radio
☐ Internet ☐ Friend ☐ Other
______
13. Have you been tested for Hepatitis B?
☐ Yes ☐ No ☐ I don’t know
a) If yes, do you know your results?
☐ Yes ☐ No ☐ I don’t know ☐ Not tested
14. Have you been vaccinated for Hepatitis B?
☐ Yes ☐ No ☐ I don’t know
a) If yes, how many shots did you receive?
☐ 1 ☐ 2 ☐ 3
b) If no, would you like to be vaccinated for Hepatitis B?
☐ Yes ☐ No ☐ I don’t know
15. Do you know someone who has Hepatitis B virus? And if yes, who?
☐ Mother ☐ Brother
☐ Father ☐ Sister
☐ Wife ☐ Daughter
☐ Husband ☐ Son
☐ Grandmother ☐ Aunty/Uncle
☐ Grandfather ☐ Friend
☐ I don’t know anyone who has hepatitis B
16. Do you know of anyone who has Liver Cancer? And if yes, who?
☐ Mother ☐ Brother
☐ Father ☐ Sister
☐ Wife ☐ Daughter
☐ Husband ☐ Son
☐ Grandmother ☐ Aunty/Uncle
☐ Grandfather ☐ Friend
☐ I don’t know anyone who has liver cancer
KNOWLEDGE
Please answer the following questions to the best of your knowledge. For each question, you can either answer yes, no, or not sure.
GENERAL HBV KNOWLEDGE / Yes / No / Not sure1. Have you ever heard of Hepatitis?
2. Have you ever heard of Hepatitis B?
3. Is Hepatitis B a viral disease?
4. Can Hepatitis B affect liver function?
5. Can Hepatitis B cause liver cancer?
6. Can Hepatitis B affect any age group?
7. Can someone with Hepatitis B have no symptoms?
8. Can Hepatitis B be transmitted from shaking hands?
9. Can Hepatitis B be transmitted through unprotected sex?
10. Can Hepatitis B be transmitted through sharing food and drinks?
11. Can Hepatitis B be transmitted through the pregnant mother to her baby?
12. Can Hepatitis B be transmitted through sharing toothbrushes?
13. Is there a treatment for Chronic Hepatitis B?
14. Is there a preventative vaccination for Hepatitis B?
15. Can Chronic Hepatitis B be cured without treatment, ie through the body?
16. Is Chronic Hepatitis B curable?
ATTITUDES
17. How did you feel when you were told you have Hepatitis B?
☐ Fear ☐ Shame ☐ Sadness ☐ Surprise
☐ Confusion ☐ Other ______
18. Who did you speak to about your diagnosis?
☐ Doctor ☐ Traditional practitioner☐ Friend
☐ Spouse ☐ Parent ☐ Other relative
19. Do you feel comfortable talking about Hepatitis B with your doctor?
☐ Yes ☐ No ☐ I don’t know
20. Do you feel comfortable talking about Hepatitis B with your family/household?
☐ Yes ☐ No ☐ I don’t know
21. Do you have any worries or concerns about your Hepatitis B?
☐ Yes ☐ No ☐ I don’t know
a) What is your biggest worry or concern about your Hepatitis B?
☐ Fear of being unwell ☐ Fear of death ☐ Fear of isolation
☐ Fear of spreading HBV ☐ Other ______
b) How concerned are you about your Hepatitis B?
☐ Extremely concerned ☐ Moderately concerned ☐ Not concerned
22. What is your biggest concern in your life right now?
______
HEALTH INFORMATION
23. How do you get information and keep in touch from your home country?
☐ Community events ☐ Radio ☐ Newspaper
☐ Internet ☐ Family/Friend ☐ TV
☐ Don’t keep in touch ☐ Other ______
24. How would you prefer to receive information about Hepatitis B?
☐ Family Doctor ☐ Specialist Doctor ☐ Radio
☐ Internet ☐ Community Forum ☐ Family/Friend
25. Do you listen to SBS radio in your native language?
☐ Yes ☐ No ☐ I don’t know
Be Positive Clinic Survey 4th May 2015 Version 2 1