Questionnaire Template

ANTHROPOMETRIC MEASUREMENTS
Child’s age: _______ Sex: Male Female

Weight at birth: _______ Unsure Length at birth: _______ Unsure
Current height: ________ Current Weight: ________
MOTHER’S KNOWLEDGE AND PERCEPTION OF EXCLUSIVE BREASTFEEDING

Do you know what exclusive breastfeeding means? Yes No
How did you acquire knowledge about exclusive breastfeeding?
Healthcare provider
Learned at school
Family or friends
Media (TV, internet, etc.)
Others Please Specify: ____________________
On a scale of 1 to 10, how important do you think exclusive breastfeeding is for the health and nutrition
of your child? (1 = Not important to 10 = Extremely important)
Rating: ________
Do you believe that exclusive breastfeeding provides all the necessary nutrients for your child's growth
and development during the first six months of life?
Yes No Not Sure
Have you faced any challenges or difficulties in practicing exclusive breastfeeding?
Yes If yes, please specify the challenges: ____________________
No
Did you seek professional advice or support to overcome any challenges you encountered during
exclusive breastfeeding?
Yes No
BREASTFEEDING PRACTICES
Was breastfeeding initiated within the first hour after your child's birth?
Yes No Not Applicable (if the child was not breastfed)
How long did you exclusively breastfeed your child?
Less than one month
1-3 months
4-6 months
More than 6 months
Were you encouraged by your healthcare provider or family members to practice exclusive
breastfeeding?
Yes No
SOCIO-DEMOGRAPHIC INFORMATION OF MOTHER
Highest Level of Education
No Formal Education Elementary
Secondary College/University
Postgraduate
Occupation
Employed Self-employed
Housewife Student
Others Please Specify: ____________________
Number of Children: _______
CHILD'S NUTRITIONAL STATUS
Has your child ever been diagnosed with malnutrition or experienced any growth-related issues?
Yes No
How would you rate your child's overall health and nutritional status?
Excellent Good Fair Poor
AWARENESS OF GOVERNMENT PROGRAMS
Are you aware of any government programs aimed at promoting good nutrition for your children who
are under 5 years old? Yes No
If yes, please specify which programs you are aware of.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
PARTICIPATION IN GOVERNMENT PROGRAMS
Have you or your child participated in any government programs related to nutrition for children under 5
years old? Yes No
If yes, please specify the program(s) you participated in.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
PERCEIVED EFFECTIVENESS OF GOVERNMENT PROGRAMS
On a scale of 1 to 5, how effective do you perceive the government programs to be in improving the
nutritional status of children under 5 years old in your community? (1 = Not effective to 5 =Highly
effective)
Rating: _____
What specific benefits or improvements have you observed in children's nutrition as a result of these
government programs?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
BARRIERS TO PROGRAM PARTICIPATION
Have you encountered any barriers or challenges that hindered your participation or your child's
participation in government nutrition programs? Yes No
If yes, please specify the barriers you have encountered.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________
SATISFACTION WITH PROGRAM IMPLEMENTATION
How satisfied are you with the implementation of government nutrition programs for children under 5
years old in your community?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
Suggestions or recommendations for improving the implementation of these programs.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________

Questionnaire Template

Uploaded by

Copyright:

Available Formats

Questionnaire Template

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Questionnaire Template

Uploaded by

Copyright:

Available Formats

ANTHROPOMETRIC MEASUREMENTS

Child’s age: _______ Sex: Male Female

MOTHER’S KNOWLEDGE AND PERCEPTION OF EXCLUSIVE BREASTFEEDING

You might also like