PATIENTS ADHERENCE LEVEL ON ANTIRETROVIRAL THERAPHY (ART): A

CONTINUOUS QUALITY IMPROVEMENT INITIATIVE

SURVEY QUESTIONNAIRE

Name (Pangalan): (Optional) __________________________________Control #: _____

I. Demographic Profile: Please provide your response to each item by placing a () to the
required answer in the box provided for.
a. Age (Edad)
12-24 years old 35-49 years old
25-34 years old 50 years old and above

b. Gender at Birth (Kasarian nung ipinanganak)

Male Female

c. Marital Status (Estado ng Kasal)

Single Married Widowed

d. Highest Educational Attainment (Edukasyon)

Never attended school
Elementary
Some high school level (level ____________)
High School graduate
Vocational level (Course _________________)
Some college (Course _________________)
College graduate (Course _________________)
Graduate Studies (Course _________________)
-- Not applicable (for non- schooling age)

e. Occupation ( Hanapbuhay)
Overseas worker (Please specify: ____________________)
Local worker (Please specify: ____________________)
Class (check one if patient belongs to category 1 or 2)
1 - professional / technical 7 - other service worker (ex. waiter)
2 - administrative / managerial 8 - commercial sex worker (CSW)
3 - clerical and related worker 9 - bar/club entertainer
4 - sales worker 10 - production workers/laborers
5 - domestic helpers 11 - agriculture/animal husbandry
6 - seaman 12 - others
Housewife
Retired
Unemployed
Student

f. Years of being diagnosed as HIV Positive (Bilang ng taon ng pagiging positibo)

Less than 1 year 4-6 years
1-3 years 7 years and above
 II. Level of Adherence of People Living with HIV/AIDS on ART
Direction: This questionnaire aims to measure the Adherence level of People Living with
HIV/AIDS on Antiretroviral Treatment. Kindly put () on each box to the corresponding item
with the legend given as follows:
Ang mga talatanungang ito any naglalayong masukat at malaman ang antas ng pag sunod ng
mga taong positibo sa HIV/AIDS sa Antiretroviral Treatment. Maarari po lamang na lagyan ng marka na
() ang kahon na katapat ng bawat katanungan na tumutukoy sa antas ng inyong pagsunod na naaayon
sa mga gabay na panukat sa ibaba:
4 Highly adherent Patient always adhere to the standards.
Palagiang Sumusunod Ang pasyente ay palagiang sumusunod sa panuntunan.
3 Moderately adherent Patient adhere to the standards.
Sumusunod Ang pasyente ay sumusunod sa panuntunan.
2 Minimally adherent Patient slightly adhere to the standards.
Bahagyang Sumusunod Ang pasyente ay bahagyang sumusunod sa panuntunan.
1 No adherent at all Do not adhere on the standards.
Hindi sumusunod Ang pasyente ay hindi sumusunod sa panuntunan.

Category 4 3 2 1
1. Diet
1.1 I eat a well-balanced meal every day.
(Kumakain ako ng prutas at gulay araw araw).
1.2 I eat foods that is high in protein regularly.
(Palagian akong kumakain ng mga pagkaing mataas sa protina)
1.3 I avoid to eat fatty and oily foods.
(Iniiwasan kong kumain ng mga pagkaing malalangis at matataba)
1.4 I less eat fast foods and junk foods.
(Hindi na ako masyadong kumakain sa fast foods at ng chicheria)
1.5 I drink 6-8 glasses of water every day.
(Umiinom ako ng 6-8 baso ng tubig araw araw)
1.6 I less drink beverages that high in coffein.
(Umiinom ako ng mga inuming mataas ang coffein paminsan minsan)
1.7 I never drink softdrinks and sweetened beverages.
(Hindi ako umiinom ng softdrinks at mamatamis na inumin)
2. Lifestyle
2.1 I can normally consume 1-3 glasses of beer in every day.
(Nakaka-ubos ako ng 1-3 baso ng alak bawat araw)
2.2 I stop smoking after Ive known my status.
(Itinigil ko na ang paninigarilyo simula ng malaman ko ang aking status)
2.3 I do not usually take drugs other than those required for medical reasons.
(Hindi ako gumagamit ng gamot maliban sa mga gamot na nireseta ng
doctor)
2.4 I do not use addictive drugs for pleasure.
(Hindi na ako gumagamit ng nakaka-adik na gamot para maglibang)
2.5 I regularly do a simple exercise to make my muscle tone
(Araw araw akong nag eehersisyo para sa aking katawan)
2.6 I take 8-10 hours of sleep daily.
(Natutulog ako ng 8 hanggang 10 oras bawat araw)
2.7 I been able to manage life stressors very well.
(Maayos kong nakakayanan ang mga stress ng buhay ko)
3. Sexual practices
3.1 I usually use condoms in every sexual encounter I do.
(Palagian akong gumagamit ng condom tuwing nakikipagtalik)
3.2 I am health conscious and practice healthy lifestyle.
(Maalam ako sa aking kalusugan at naniniguradong malusog ang aking pamumuhay)
3.3 I do not engage into party and play.
(Hindi ako dumadalo sa mga kasiyahang nauuwi sa pakikipagtalik)
3.4 I do not practice substance abuse.
(Hindi ako manginginom (alak) o lulong sa pinagbabawal na gamot)
3.5 I do not engage into casual sex.
(Hindi ako nakikipag talik basta basta, minsana mga taong ngaun ko lang nakilala)
4. Laboratory monitoring
4.1 I usually go to my scheduled annual laboratory.
(Palagian akong pumupunta sa aking taunang pagkuha ng dugo.
4.2 I have my CD4 tested every 6 mos.
( pinapagawa ko ang aking CD4 tuwing ika 6 na buwan)
4.3 I promptly attend to the requested diagnostics of my physician
(Palagian akong pumupunta sa tuwing may ipinapagawang laboratory ang aking doctor)
5. Follow up check up
5.1 I regularly see my doctors whenever I feel ill.
(Palagian akong pumupunta sa aking doctor kapag may sakit)
5.2 I usually visit my doctor as per schedule.
(Palagian akong pumupunta sa aking doctor upang magpa konsulta)
5.3 I usually follow the scheduled refill of my medication
(Palagian akong pumupunta sa aking hub para kumuha ng gamot)
6. Antiretroviral drugs
6.1 I religiously refill my ARV 2 weeks before I consume the last pill
(Palagian akong kumukuha ng gamut 2 linggo bago ito maubos)
6.2 I usually take my medication religiously on time.
(Palagian akong umiinom ng gamot sa oras)
6.3 I regularly use alarm clock to remind me to take my meds.
(Palagian akong gumagamit ng alarm para maalala ko ang pag inum ng gamot)
6.4 I usually use pill boxes for my ARV adherence
(Palagian akong gumagamit ng pillboxes)
6.5 I make sure to have a pill in all of my bags when travelling.
(Sinisigurado ko na lagi akong may dalang gamot kapag bumibiyahe)
6.6 I often follow special instructions such as take with foods or :on empty
stomach
(Palagian kong sinusunod ang mga panuntunan sapag inon ng gamot)