Zuletzt aktualisiert: 10. Dezember 2021 von admin

Survey

Welcome to your Survey

1. When were you born? [DD.MM.YYYY]

2. What gender are you?

Female Male

3. How is your health situation in general?

very good good average bad very bad

4. Do you have one or more long term chronic diseases?
(Chronic diseases are long- lasting diseases requiring continuous treatment and control, like diabetes or heart diseases.)

yes (please note the diseases in the next text field) no I don't know

4.1. Diseases (for question 4)

5. To what extent are you permanently restricted by disease in the exercise of your daily activities? (At least the last six months.)

severely restricted slightly restricted not restricted I don't know

6. Please state your religious belief.

Catholic Protestant Muslim Jewish Orthodox Budhistic Atheist Other (fill in the next Text field)

6.1. Other religious belief. (for question 6)

7. How many times a week do you visit your church/ mosque/ synagogue/ etc.?

1x/week 2x/week 3x/week more than 3x/week

8. Do you have a disability that is officially recognized by the pension office?

Yes (please note the percentage in the next text field) No

8.1. What percentage is the degree of disability at present? (in %)

9. Which people live with you in your household?
Example:
Person - age - gender
Partner - 36 - f (for female)

13. How do you rate your german language skills?

... speaking:

native speaker good sufficient little not at all

... writing:

native speaker good sufficient little not at all

... reading:

native speaker good sufficient little not at all

14. Education in Germany: What is the highest degree you have achieved?

completed primary school

secondary school

"Fachhochschulreife"

high school, general or technical high school

finished school with no qualifications

do not have any graduation

other (fill in the next text field)

15. Schooling in your home country: What is the highest school degree you have?

still in school

finished school with no qualifications

completed primary school

completed secondary school

completed high school

other (fill in the next text field)

16. What is the highest professional qualification you have achieved?

still in vocational training (trainee / student / vocational training year)

no vocational qualification and not in vocational training

completed vocational job training (apprenticeship completed)

vocational school education (vocational school, business school, preparation service for the middle grade in public administration completed).

training at a technical college, master-, technical school, vocational or technical Academy completed

completed bachelor of (technical) college

any specialisation degree from an university of applied sciences or school of engineering

any degree from an university or college

other degree (fill in the next text field)

17. Are you currently employed? Employment here includes any income-related /paid occupation, disregarding the (contract) and/or period.

full-time employed

part-time employed

part-time employed (450€- or Mini-Job)

„one-euro-job“

occasionally or irregularly employed

vocational education / apprenticeship

temporarily exempted / on leave (e.g. parental leave)

not employed

18. Which is your current professional position?

... employee:

ordinary employee (e. G. TVöD E1-E4)

middle class employee (e.G. TVöD E5-E8)

elevated employee (e.G. TVöD E9-E12)

higher employee (TVöD E13- 15 )

... civil servant:

basic service (A1-4)

middle class service (A5- 8)

elevated service (A9-13)

higher service (A14-16)

19. Does one of the following statements apply to your current situation?

semi retirement

in retirement / pension since (fill in the next text Box)

unemployed, since (fill in the next text Box)

retraining

internship, volunteer

housewife / houseman

20. When was the last time you have required medical support from a doctor, dentist or their medical staff?

during the last 4 weeks

in the last 1-3 months

12 months up to 5 years ago

more than 5 years ago

... did the practitioner have an immigration background?

Yes

I don't know

21. Do you have a family doctor whom you consult first with health issues/ problems?

Yes

23. Have you been requiring (first) aid from an ambulance/ an emercengy room during the last 12 months (treatment without being admitted to the hospital// as an ambulant patient// excluding treatment you have received as an inpatient).

Yes (please note how often in the next text field) No

... how often did you require (first) aid from an ambulance/ an emercengy room during the last 12 months?

24. Have you been advised on any of your ambulant visits during the last 12 months regarding to your health behaviour?

Yes No

... if so the advice regarded the following subjects/aspects. (Multiple answers possible)

... your Diet?

... your Weight?

... your sport activity?

... your smoking?

... your immunization?

... your alcohol consumption?

... stress Management?

... your dental care?

... your general life circumstances?

... your professional situation?

... use of drugs?

... sexual behavior?

... something else? (please nite the subjects/aspects in the next text field)

... subjects/aspects:

25. How many nights did you spend at a hospital as an inpatient during the last 12 months? (from 0 to X)

27. How many calendar days have you been absent at work due to illness. Please include the days you have been admitted at the hospital/ as an inpatient.

28. In case you are contracted ( a contracted worker) please state how many days you have been on sick-leave admitted by a physician during the last 12 months. Please include the days you have been admitted at the hospital/ as an inpatient.

none

Does not apply to me

more that 0 (Please not the number in the next text field)

... number (see question 28)

29. How many nights in the last 12 months have you been on inpatient treatment in a hospital? (from 0 to X)

31. The participation in health check-ups/ a health examination for early diagnosis/recognition of diabetes, cardio-vascular- and kidney diseases is offered by the health insurances from the age of 35 years every two years.

... are you aware of those offers?

Yes No

... did you ever participate in any health check-up?

Yes No I don't know

... did you participate in any health check-up in the last 2 years?

Yes No I don't know

32. Dental screening examinations are also recommended for adults. The german health care system provides two free of charge dental examinations a year, called dental control examination.
Are you participating regularly, – at least once a year- in a dental control examination?

Yes No

33. Which health insurance are you contracted with?

Legal health Insurance (actualy) Local health Insurance (AOK)

Replacementinsurance (e.g. Barmer, TK, DAK, KKH)

Plant health insurance

Guild health insurance (IKK)

Seainsurance, agricultureinsurance, „Knappschaft“, Pensioninsurance,

Completly Private Insurance

Foreign Insurance

Other claim on health care (e. g. free medical care, welfare, War Damage pension)

No Insurance, Self-payer.

... do you have an complementary insurance policy in addition to the mentioned one above?

Yes No

... allowance

... if you are not sure which category your insurance belongs to, please state the exact name here:

34. General health condition
How would you describe your general health condition?

excellent very good good lacking poor

35. In comparison to last year, how would you describe your current health condition?

Now much better then last year

Now a little better then last year

Much like last year

Now worse then last year

Now much worse then last year

36. Following you find a list of activities you may perform on a daily basis.
If your state of health sets limits to performing these activities, please state the degree of restriction?

... exhausting activities (e.g. fast running, lifting heavy objects, strenuous exercise):

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... moderate activities (e.g. moving a table, vacuuming, bowling, playing golf):

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... lifting or carrying shopping bags:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... climbing a flight of steps:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... climbing a staircase:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... bowing, kneeling, bending down:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... walking more than 1 km by foot:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... walking several hundred metres by feet:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... walking one hundred metres by foot:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

... bathing or putting on clothing:

Yes, strongly restricted Yes, somehow restricted No, not at all restricted

37. Did you- due to your physical health condition- experience any difficulties at work or performing work related activities within the last 4 weeks?

... I could not be active as long as usual..

always often sometimes rarely never

... I have accomplished less than I wanted.

always often sometimes rarely never

... I could only do certain things.

always often sometimes rarely never

... I had difficulties performing (for example I had to make
a special effort).

always often sometimes rarely never

38. Did you- due to your mental (health) condition- experience any difficulties at work or performing work-related activities within the last 4 weeks? (for example because you felt depressed or anxious)?

...I could not be active as long as usual.

always often sometimes rarely never

... I could only do certain things.

always often sometimes rarely never

... I had difficulty performing (for example I had to make
a special effort).

always often sometimes rarely never

... I have accomplished less than I wanted.

always often sometimes rarely never

39. Did any physical or mental health conditions affect your interaction with family members, friends, neighbours or colleagues at work during/within the last 4 weeks?

Yes, strongly restricted No

... If yes, how?

not at all somehow moderate considerable very

40. Have you been in pain within the last 4 weeks?

no pain very low low moderate strong very strong

41. To what extend has the pain hindered you performing your daily activities during the last 4 weeks ( at home and at work)?

Not at all somewhat moderately strong very strong

42. The following questions deal with your emotional state. We would like to ask you how you feel and how you have been doing. Please mark one choice for every line/row: Considering the last 4 weeks how often did you feel....

... full of energy?

always / usually sometimes rarely never

... very nervous?

always / usually sometimes rarely never

... so depressed that nothing could cheer you up?

always / usually sometimes rarely never

... calm and relaxed?

always / usually sometimes rarely never

... discouraged and sad?

always / usually sometimes rarely never

... exhausted?

always / usually sometimes rarely never

... happy?

always / usually sometimes rarely never

... tired?

always / usually sometimes rarely never

43. Did your mental health condition affect your social behaviour, the way or frequency you interact with other people e.g. visiting relatives or friends?

Yes No

always mostly sometimes rarely never

44. To what extent does each of the following statements apply to you?

... I seem to get easier sick than other people.

applies completly applies largely i dont know applies largely not doesnt apply at all

... I'm as healthy as other people I know.

applies completly applies largely i dont know applies largely not doesnt apply at all

... I expect that my health is deteriorating.

applies completly applies largely i dont know applies largely not doesnt apply at all

... my health is excellent.

applies completly applies largely I don't know doesn't apply largely doesnt apply at all

... how many times a week do you practice physical exercise until you feel out of breath or you sweat?

less than 10 minutes

10 to under 30 minutes

30 to under 60 minutes

more than 60 minutes

46. How much attention do you pay to adequate physical exercise overall?

very strong strong partly not much not at all

47. How often do you exercise?

No exercise

Less than 1 hour a week

Regularly, 1-2 hours a week

Regularly, 2-4 hours a week

Regularly, more than 4 hours per week

48. These questions are about the way you felt whilst using health care services // being under treatment. Please cross the box for the option that applies most.

... did you understand the diagnosis you were given?

always sometimes rarely never

... if you did not understand it at the first time –how often did you try to ask again to get a better understanding of your diagnosis?

always sometimes rarely never

... how often did the doctor in charge help you so you were able to understand everything?

always sometimes rarely never

... how often were you able to find someone helping you to understand your diagnosis?

always sometimes rarely never

49. What do you believe was the reason that kept people from helping you (to understand your diagnosis)?

language technical terms lack of time not willing to i dont know

50. Did you or a family member or a loved one became seriously ill, or did you suffer from delayed recovery, due to the fact that you did not understand your diagnosis or due to the lack of understanding that kept you from following medical advice?

Yes No I don't know

51. If you do not use the health care system, what do you do to stay healthy?

... do you think that it is sufficient?

Yes No I don't know

52. Do you believe to be solely responsible for your health, or do you see others responsible to keep you healthy such as for example doctors?

... I'm all solely responsible

applies applies somehow does not apply

... the doctor and the health system are responsible.

applies applies somehow does not apply

53. Are you willing to follow any of your doctors advice to gain/regain health?

Yes No I don't know

54. What would be helping you to increase confidence in your doctor?

capability Language nationality titel other (please state in the next box)

55. How many times did you understand the diagnosis, but the treatment did not help any?

always often sometimes rarely never

56. Do you think the range of services provided by doctors/physicians/translators of your nationality and/or speaking your language is sufficient?

Yes No I don't know

57. Having the same symptoms, would you go and see a doctor sooner in your home country than in Germany?

Yes No I don't know

... did you postpone a necessary visit at the doctor here in Germany to be attended by a doctor in your home country (e.g. during a trip/vacation)?

always often sometimes rarely never

... if yes, why?

better Treatment less costs language more confidence

58. Could the treatment also have taken place in Germany?

Yes No I don't know

60. Do you think the medicine in your homeland is better than in Germany?

Yes No I don't know

... Do you also use alternative medication to cure what you have been diagnosed with?

Yes No Sometimes only if everything else failed to help

61. In these questions, we would like to ask you how much you feel better and more helped with to discuss any health issue/question with your spiritual representatives (Pastor / Iman / Rabbi / e.g..) compared to the representative of the health system (doctor / therapist / e.g.)? .... ( Please cross the box on each line that applies best.)

... I always go first to a spiritual representative.

applies completly applies largely i dont know applies- largely not doesnt apply at all

... my spiritual representative understands me better and can help me better.

applies completly applies largely i dont know applies- largely not doesnt apply at all

... how often are you being referred to a doctor by your spiritual representatives?

applies completly applies largely i dont know applies- largely not doesnt apply at all

62. Is there anything about health or religion that you would like to tell us because it's important to you or because it did not occur in the survey?

Yes No

Thank you for taking part in this survey!

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