Gender
Male
Female

Age
 

1. Race/Religon
 

2. Education Status
Illiterate
Can Read/ Write
Grade 1-4
Grade 5-8
Grade 9-10
University
Graduate

3. Occupation
 

4. Current Marital Status
Single
Married
Divorced
Widow

5. When were you Married?
 

6. Do you read during leisure time?
No
Yes
Newspaper
Journal
Magazine
Novel
Cartoon
Others

7. Do you usually listen to the radio?
Yes
No

8. Do you watch TV? MRTV Or MWD
Yes
No

9. Where/Whom do you get most of the health knowledge from?
Radio
TV
Magazine/NewLetters
Health worker
Social worker
Friends
Teachers
Partents/Relatives
Others

10. Did you ever drink like alcohol,beer,toddy juice in the past year?
Never
Less than once a week
Once a week
More than once a week
Social worker
Everyday

11. Did you try injecting illegal drugs last year?
Yes
No