Region 1

Division of Ilocos Norte

SARRAT NATIONAL HIGH SCHOOL
Brgy. 4 San Francisco, Sarrat Ilocos Norte
Appendix-A

Date: __________________
The Respondents

Good Day!
The undersigned Senior High School Students of Sarrat National High School is
requesting your time and appreciation in the conduct of their study entitled THE RISK
FACTORS OF HYPERTENSION AMONG YOUNG ADULTS IN SARRAT, ILOCOS
NORTE in your school, by answering our survey questionnaire form. Your responses will be
kept confidential and will be used for research purposes only.
This study shall be undertaken in partial fulfilment of the requirements in Practical
Research II under the Senior High School Curriculum. Anticipating your favorable action and
cooperation. Thank you very much and God Bless!

Very Truly Yours,

_______________________________
NATHALIA EICELLROSE BUENO

_______________________________
ASHLEY KATE EUGENIO

_______________________________
DAWN ANGEL RAMOS

Noted by:

MRS. JONABELLE J. AGOO

Research Adviser
 Region 1
Division of Ilocos Norte
SARRAT NATIONAL HIGH SCHOOL
Brgy. 4 San Francisco, Sarrat Ilocos Norte
Appendix-A

Date: __________________
Letter to the Principal

Good Day Ma’am!

The undersigned Senior High School Students of Sarrat National High School is
requesting your permission in the conduct of their study entitled THE RISK FACTORS OF
HYPERTENSION AMONG YOUNG ADULTS IN SARRAT, ILOCOS NORTE in the
different barangays of Sarrat, Ilocos Norte.
This study shall be undertaken in partial fulfilment of the requirements in Practical
Research II under the Senior High School Curriculum. Anticipating your favorable action and
cooperation. Thank you very much and God Bless!

Very Truly Yours,

_______________________________
NATHALIA EICELLROSE BUENO

_______________________________
ASHLEY KATE EUGENIO

_______________________________
DAWN ANGEL RAMOS

Noted by:

MRS. JONABELLE J. AGOO

Research Adviser

DR. MARIETTA B. YAP

School Principal IV
 Region 1
Division of Ilocos Norte
SARRAT NATIONAL HIGH SCHOOL
Brgy. 4 San Francisco, Sarrat Ilocos Norte
Appendix-B

Date: __________________
The Barangay Chairman

Ma’am/Sir!
Good Day!

The undersigned Senior High School Students of Sarrat National High School is
requesting your permission for the conduct of their study entitled THE RISK FACTORS OF
HYPERTENSION AMONG YOUNG ADULTS IN SARRAT, ILOCOS NORTE in your
school.
This study shall be undertaken in partial fulfilment of the requirements in Practical
Research II of the Senior High School Divisions. Anticipating your favorable action and
cooperation. Thank you very much and God Bless!

Very Truly Yours,

_______________________________
NATHALIA EICELLROSE BUENO

_______________________________
ASHLEY KATE EUGENIO

_______________________________
DAWN ANGEL RAMOS
Noted by:

MRS. JONABELLE J. AGOO

Research Adviser

Approved by: _______________________

BARANGAY CAPTAIN
(Signature over printed name)
 Appendix-C

QUESTIONNAIRE

(SURVEY FORM)
Dear Respondent,

Good Day! We would like to ask for your help by accomplishing this survey form.

Rest assured that your identity will remain confidential. The results will be used for the

completion of our thesis. Kindly give the information and check the questions accordingly.

I. Personal Information:

Name: ___________________________________________ Age: ______Sex: ___________

Home Address: ______________________________________________________________

Occupation_________________________________ Weight: __________Height:_________

II. General Health Information

1. Have you had a flu shot?
If yes, what was the date of your last flu shot? _____________________
a) Yes
b) No
c) Don’t know

2. Have you had a pneumonia shot?

If yes, what was the date of your last pneumonia shot? _____________
a) Yes
b) No
c) Don’t know

3. Are there any other medical problems you are being treated for?
If yes, please explain: ________________________________________________________
__________________________________________________________________________
a) Yes
b) No
c) Don’t know
4. In the last 6 months, have you been to the emergency room (ER) for hypertension? If yes,
how many times? ________
a) Yes
b) No
c) Don’t know

5. What are your health goals and interests?

a) Eating better
b) Exercising
c) Reducing stress
d) Aging well
e) Losing weight
f) Other
g) None

III. Medication Information

6. Have you been prescribed any medication to lower your blood pressure?
a) Yes
b) No
c) I do not know

7. If yes, what prescription medications do you take? Please list:

_________________________________________________________________________
________________________________________________________________________

8. Do you take non-prescription medications or supplements (for example, aspirin, vitamins,

etc.)? If yes, please list: _______________________________________________________
a) Yes
b) No
c) Don’t know
9. Has your doctor told you that you have High Blood Pressure?
a) Yes
b) No
c) Don’t know
10. How often do you see your doctor for blood pressure checkups?
a) monthly
b) every 3-4 Months
c) every 6 months
d) once a year

11. What was your last systolic blood pressure reading? (Top number) _____
a) Don’t know

12. Your last diastolic blood pressure reading? (Bottom number) _____
a) Don’t know

13. Have you had a blood pressure reading of 140/90 or less in the last year?
b) Yes
c) No
d) Don’t know

14. Which of the following symptoms have you had?

a) Blurry Vision
b) Chest Pain
c) Dizziness
d) Headaches
e) None
f) Other____________________________________

15. Does high blood pressure affect the ability to perform your usual daily activities? If yes,
how? ____________________________________________________________________
a) Yes
b) No
c) Don’t know

16. Select the type of diet you are following.

a) Diabetic
b) Low Carbohydrate / Sugar
 c) Low Cholesterol
d) Low Salt
e) Renal (Low Protein/Low Salt)
f) Weight Reduction
g) Vegetarian
h) No Special Diet
i) Yes No Don’t know

17. How did you come to know about? Your hypertension?

a) in a routine medical control
b) Screening Program
c) Emergency service
d) Other (specify:_______________________)
e) I do not know

18. When were you diagnosed for the first time?

a) Less than 5 years
b) More than 5 years

19. Where were you first diagnosed for having hypertension?

a) This primary health center
b) Other primary care clinic/physician
c) Secondary care hospital
d) Tertiary care hospital
e) at a pharmacy/drugstore
f) other (specify)
g) I do not know

20. Where do you regularly go for routine follow up to check your blood pressure?
a) Diagnosis on this visit
b) This health center
c) Nearby primary health care clinic
d) Nearby hospital (secondary facility)
e) Tertiary hospital
 f) I do not do any routine follow up

21. What foods do you commonly eat before you got diagnose with hypertension?
(Select at least 4)
a) Fatty foods
b) Veggies and fruits
c) Sweets
d) Junk foods
e) Preserved Foods
f) Sodas
g) Grilled foods

22. What type of physical activity do you currently do?

a) Aerobic Workout Bicycling
b) Running/Jogging Swimming
c) Walking None

23. How often do you do physical activity?

a) 1-3 times a week
b) 3-5 times a week
c) 5-7 times a week
d) inconsistently
e) none

24. Do you smoke cigarettes? If yes, how many cigarettes a day? _______
a) Yes
b) No
c) Don’t know

25. If your answer to question no. 24 is yes, how many years/ months have you been
smoking?
a) Less than 1 year
b) More than 1 year
26. Does anyone in your house smoke?
a) Yes
b) No
c) Don’t know

27. Do you drink alcohol? If yes, how much _______?

a) Yes
b) No
c) Don’t know

28. Do you have blood relatives with history of hypertension?

a) Yes
b) No
c) I do not know

29. Over the last year have you been admitted to the hospital?
a) Yes
b) No

30. Have you had any complications from your hypertension?

a) renal disease
b) stroke
c) retinopathy
d) cardiovascular
e) other____________
f) I don’t know