PENGKAJIAN KESEHATAN KOMUNITAS

IDENTITAS
Nama :
Usia :
Jenis Kelamin :
Agama :
Suku atau Etnis :
Status menikah :
Pendidikan terakhir :
Pekerjaan saat ini :
Alamat :

QUESIONER :
1. Apa pendapat saudara, terkait keadaan di lingkungan sekitar anda, baik di rumah atau
di lingkungan masyarakat ?
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2. Apakah pada lingkungan masyarakat terdapat fasilitas layanan kesehatan?, sebutkan.
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3. Apakah ada kegiatan di masyarakat sekitar terkait kesehatan dan pelayanan sosial
yang sering anda ikuti ?, sebutkan.
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4. Apakah jarak dari tempat tinggal anda ke fasilitas kesehatan cukup jauh, ataukah
dekat?, sebutkan
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5. Apakah alat transportasi dan keamanan yang anda gunakan untuk menjangkau
fasilitas kesehatan yang ada pada lingkungan sekitar ?
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6. Apakah pada komunitas masyarakat sekitar memiliki layanan politik dan
pemerintahan yang anda ketahui? Sebutkan, dan jelaskan
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 7. Apakah anda memilki perbedaan suku dan budaya dengan masyarakat sekitar tempat
tinggal anda ?
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8. Bagaimana, komunikasi yang anda lakukan dengan masyarakat sekitar ?
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9. Kegiatan seperti apa yang sering anda lakukan dengan tetangga atau masyarakat
sekitar?
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10. Apakah, anda sering melakukan kegiatan rekreasi, jika memiliki waktu luang atau
pada hari libur ?
- Rekreasi apa yang sering dilakukan di luar rumah ?
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- Rekreasi apa yang sering dilakukan di dalam rumah pada hari libur ?
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PERSEPSI KESEHATAN :
1. Apakah akhir-akhir ini anda mengalami keluhan terkait masalah kesehatan ?
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2. Apakah anda mengetahui penyebab dari keluhan masalah kesehatan tersebut?
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3. Apa gejala yang sering anda rasakan dan keluhkan ?
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4. Kapan terakhir kali anda merasakan hal tersebut ?
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5. Apa penanganan yang anda lakukan untuk mengatasi nya?
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 6. Apakah anda menggunakan obat-obatan herbal atau tradisional dalam mengatasi
permasalahn kesehatan ?
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7. Apakah anda memanfaatkan layanan kesehatan disekitar masyarakat sebagai langkah
awal dalam permasalahan ?
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8. Kapan terakhir kali anda pergi memeriksakan kesehatan anda ke fasilitas kesehatan ?
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9. Menurut, anda bagaimana fasilitas kesehatan atau layanan kesehatan dimasyarakat
sekitar ?
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10. Bagaimana, persepsi atau pendapat pribadi anda terkait kesehatan ?
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QUESIONER TERKAIT DISMINORE

1. Apakah saudara mengetahui apa itu disminore atau pengertian umum dari disminore?
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2. Apakah saudara mengetahui penyebab dan tanda gejala dari disminore yang
diarasakan ?
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3. Seberapa sering saudara merasakan disminore ?
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4. Kapan disminore tersebut saudara rasakan ?
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5. Apakah ada aktivitas fisik yang mempengaruhi anda terkait masalah disminore yang
anda rasakan?
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6. Apakah ada pengobatan atau obat-obatan yang saudara gunakan untuk menangani
disminore tersebut ?
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7. Apakah menurut anda masalah terkait disminore harus segera di tangani atau tidak?
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8. Apakah menurut anda, disminore adalah masalah kesehatan yang sangat berbahaya?
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9. Kapan terakhir anda memeriksakan diri terkait masalah nyeri yang anda rasakan di
rumah sakit, puskemas atau layanan kesehatan lainnya?
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10. Bagaimana persepsi atau pendapat saudara pribadi terhadap masalah kesehatan
disminore ?
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**Terima Kasih Atas Partisipasinya**