1. COMPILED BY MARA KETTLE AND NICOLAS FESSER
SUSTAINABLE HEALTHY LIVING PROJECT
NEEDS ASSESSMENT QUESTIONNARE 2016
WEST AFRICA AIDS FOUNDATION CENTER
Email: info@waafweb.org
Tel: +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:____________________

2. 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/No
If 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________________________________________________________
_____________________________________________________________________________
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How do you spend your monthly, weekly, or daily income?
_____________________________________________________________________________
_
_____________________________________________________________________________________

3. 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____________________________________________________________

4. 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/No
If 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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5. All Rights Reserved. WAAF 2016.

6. All Rights Reserved. WAAF 2016.