1. SURVEY FORM ABOUT
HEART DISEASES
1. What is your age group?
[ ] 21 - 25
[ ] 26 - 30
2.How much did you understand about heart diseases?
[ ] 0% - 40%
[ ] 41% - 80%
[ ] 80% & Above
3. Where is the location of heart in body part?
[ ] Left side of chest
[ ] Right side of chest
[ ] Middle of chest
4. What is the function of heart?
[ ] Pumps oxygen-rich blood to every organ in body
[ ] Keeps the body pure of toxins and harmful substances
[ ] Receives input from the sensory organs
5. Which of the following is an example of heart disease?
[ ] cardiovascular diseases
[ ] Stroke
[ ] coronary artery disease
6. Is there any differences between hearts of men and women?
[ ] Yes
[ ] No
7. What is the normal rate of heart beating? ( ) Times/minute
[ ] 60 - 99
[ ] 100 -130
8. Which gender that you think will have higher percentage of getting heart diseases?
[ ] Male
[ ] Female
[ ] Both are same
9. Which ages category do you think that have higher percentage to get heart diseases?
[ ] 21 - 30
[ ] 31 - 40
[ ] 41 - 50
[ ] 51 & Above
10. Do you think heart diseases will affected the next generation?

2. [ ] Yes
[ ] No
11. Do you think feeling weak or faint are symptoms of a heart attack?
[ ] Yes
[ ] No
[ ] Don’t know / Not sure
12. Do you think heart disease will affected your daily life?
[ ] Yes
[ ] No
[ ] Don’t know / Not sure
13. Which is the way to prevent heart disease?
[ ] Eat more fruits & Do more exercise
[ ] Control your meal daily
[ ] Go for body check up twice a year
14. If you thought someone was having a heart attack, what is the first thing you would
do?
[ ] Take them to the hospital directly
[ ] Tell them to call their doctor
[ ] Call 911
[ ] Do something else that could help them
[ ] Don’t know / Not sure
15. Death rate of heart disease.
[ ] 0% - 30%
[ ] 31% - 60%
[ ] 61% - 90%
[ ] 90% & Above