COMPILED BY MARA KETTLE AND NICOLAS FESSER

SUSTAINABLE HEALTHY LIVING PROJECT

NEEDS ASSESSMENT QUESTIONNARE 2016

WEST AFRICA AIDS FOUNDATION CENTER

Email: info@waafweb.orgTel: +233 302 541 220/ +233 243 362 447

A) PATIENT BACKGROUND

Name____________________________ Date______________________________________

Phone Number______________________ WAAF ID_________________________________

Please Circle One

Gender: Female/ Male Date of Birth_____________ Age____________________

Age Group: __under 18__18-25__26-35__36-55__56-65__over 65

EMPLOYMENT

Please Circle One

Employed: Yes/No Retired

If yes, please indicate profession __________________________________________________

Level of Education_____________________________________________________________

Language(s) Spoken a) TWI b) ENGLISH c) both a and b Other________________

Please Circle One

Marital Status: a) Single b) Married c) Divorced d) Widow

Religion_______________________________

Residential Address____________________________________________________________

Next of Kin:____________ Relationship:________________ Tel No:____________________

B) HEALTH STATUS

Please Circle One

Diagnosis--- a) HIV b) TB c) both a and b d) other___________________________

Date of test(s)_________________________________________________________________

Treatment Plan________________________________________________________________

Medication(s) _________________________________________________________________

Health Facility_________________________________________________________________

Referral Program(s) ____________________________________________________________

Do you have health insurance? Yes/No

If yes, what type of insurance do you have?_________________________________________

Do you and/or anyone in your family currently have any disabilities/impairments? Yes/NoIf yes, please explain____________________________________________________________

Did you disclose your status to any friends/and or family member(s) Yes/No

If yes, please state who__________________________________________________________

C) FINANCIAL STATUS

Please Circle One

Do you earn a) monthly income? b) weekly income? c) daily income?

If yes, please indicate how much __________________________________________________

If no, please explain why________________________________________________________

______________________________________________________________________________

How do you spend your monthly, weekly, or daily income?

______________________________________________________________________________

_____________________________________________________________________________________

OVERVIEW OF EXPENSES

Please indicate whether each field provided is a daily (dly), weekly (wkly), or monthly (mtly) expense and provide an estimate cost for all fields that are applicable to you.

Transportation______________ Food________________ Utilities_____________________

Phone______________________ School Fees_________________ Medications____________

Miscellaneous_______________ Medical Fees________________ Rent__________________

Other expenses________________________________________________________________

D) HOUSEHOLD/FAMILY INFO

How many people including you live in the home? ___________________________________

How many square meals do you have in a day? _____________________________________

Please Circle One

How satisfied are you with the quantity of these meals? Poor/Satisfactory/Good/Excellent

Do you have any extra assistance in terms of finances? Yes/No

>>>If yes, please identify who gives you the additional support________________________

______________________________________________________________________________

>>>If no, do you wish for extra support? Yes/No

E) FURTHER INFORMATION

Do you have any hindrances that may prevent you from continuing your treatment? Yes/No

If yes, please explain____________________________________________________________

______________________________________________________________________________

Are you currently taking any non-prescribed and/ or illegal drugs? Yes/No

If yes, please explain____________________________________________________________

If you are identified as a client in need of additional assistance, would you be comfortable and willing for project staff to visit your home for further information? Yes/NoIf yes, what days of the week are you best available?

Please Circle Your Availability

M/T/W/TH/F/S Morning (8am-11am) Afternoon (12pm-3pm)

M/T/W/TH/F/S Morning (8am-11am) Afternoon (12pm-3pm)

Do you give project staff permission to access your medical, financial, and or any other relevant information pertaining to this project and your selection? Yes/No

Patient Signature X___________________________ Date: _______________________

Staff Signature X___________________________ Date: _______________________

Supervisor Signature X________________________ Date: ________________________

______________________________________________________________________________

For Departmental Staff Use Only:

Follow Up Yes/No If no, please explain _______________________________________

Home Visit Date: Time: AM/PM

Project Staff Attending:

Further Notes

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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All Rights Reserved. WAAF 2016.

All Rights Reserved. WAAF 2016.