{"slug": "self-complete-questionnaire-in-english", "title": "Self Complete Questionnaire in English", "pdfUrl": "https://dhir.gov.mt/wp-content/uploads/2024/04/Self_Complete_Questionnaire_in_English.pdf", "sourcePage": "https://dhir.gov.mt/en/surveys/european-health-interview-survey-2019-2020-ehis/", "group": "Survey", "topic": "European Health Interview Survey 2019 2020 Ehis", "tables": [{"caption": "Table 1: Your answers will remain confidential and will be used for statistical purposes only", "header": ["SC.1  The self-completion form is being answered by the: (Tick one box ONLY)Selected Individual                                          o\u2081Interviewer                                               o\u2082Other (specify)______________________________________________________    o\u2083"], "rows": [["SMOKING"], ["SK.1  Do you smoke any tobacco products (excluding electronic cigarettes or similar electronic devices)?(Tick one box ONLY)Yes, daily                                                o\u2081Yes, occasionally                                            o\u2082Not at all                                                o\u2083\u2192 SK.5"], ["SK.2  What kind of tobacco product do you mostly consume?  (Tick one box ONLY)Choose the one product you smoke most oftenCigarettes                                               o\u2081\u2192 SK.3Manufactured and/or hand rolledCigars                                                 o\u2082Pipe/tobacco                                             o\u2083Heated tobacco products (e.g. iQOS, Glo, Pax, etc.)                       o\u2084 \u2192 SK.2AShisha                                                 o\u2085Other (specify) _________________________________________________________  o\u2086If you answered \u2018daily\u2019 in question SK.1 go to question SK.6SK.2AIf you answered \u2018occasionally\u2019 in question SK.1 go to question SK.5SK.3  How often do you smoke cigarettes? (Tick one box ONLY)Daily                                                   o\u2081Occasionally                                              o\u2082\u2192 SK.5"], ["SK.4  On average, how many cigarettes do you smoke each day?Manufactured and/or hand rolled.\u2192 SK.6"]]}, {"caption": "Table 1: Your answers will remain confidential and will be used for statistical purposes only (cont. 2)", "header": ["SK.5", "(Tick one box ONLY) Yes No", "Have you ever smoked cigarettes, cigars, pipes or other tobacco products daily, for at least 12 months?", "", "", "", ""], "rows": [["SK.5", "(Tick one box ONLY) Yes No", "", "", "", "o\u2081", "\u2192 SK.7"], ["SK.5", "(Tick one box ONLY) Yes No", "", "", "", "o\u2082", "\u2192 SK.7"], ["SK.6", "For how many years have you smoked daily? Count all separate periods of smoking daily. If you do not remember the exact number of years, please give an estimate.", "", "", "", "", ""], ["SK.7 How often are you exposed to tobacco smoke indoors in these places? (Tick one box PER ROW)", "", "", "", "", "", ""], ["", "", "1 hour or more per day", "Less than 1 hour per day", "once a week, but not everyday", "Less than once a week", "almost never"], ["", "Indoors at home? In indoor public spaces and/or in transport?", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085"], ["", "E.g. bars, restaurants, shopping malls, arenas, bingo halls, bus, etc.", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085"], ["", "Indoors at the workplace?", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085"], ["SK.8", "Do you currently use electronic cigarettes or similar electronic devices? (Tick one box ONLY)", "", "", "", "", ""], ["SK.8", "E.g. Electronic-shisha, electronic pipe", "", "", "", "", ""], ["SK.8", "Yes, daily vaping", "", "", "", "o\u2081", ""], ["SK.8", "Yes, occasionally vaping", "", "", "", "o\u2082", ""], ["SK.8", "No, but I did in the past", "", "", "", "o\u2083", ""], ["SK.8", "Never vaped", "", "", "", "o\u2084", ""], ["SK.9", "During the past 7 days, including today, did you smoke a shisha pipe/hookah pipe? (Tick one box ONLY)", "", "", "", "", ""], ["SK.9", "Yes", "", "", "o\u2081", "", ""], ["SK.9", "No", "", "", "", "o\u2082", "\u2192 AL.1"]]}, {"caption": "Table 3: If questionnaire is answered by a proxy, go to question OP.1", "header": ["If questionnaire is answered by a proxy, go to question OP.1", "", "", "", "", "", "", "", "", ""], "rows": [["If questionnaire is answered by a proxy, go to question OP.1", "", "", "", "", "", "", "", "", ""], ["CN.1", "", "Have you ever tried any of the substances listed below? (Tick one box PER ROW)", "", "", "", "Yes, within", "Yes,", "", ""], ["", "", "", "", "", "Yes, within the past month", "the past 12 months (but not within the past month)", "previously (but not within the past 12 months)", "", "No, I have never tried the substance"], ["", "Tranquilisers/Sedatives with", "a doctor\u2019s prescription", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Tranquilisers/Sedatives without", "a doctor\u2019s prescription", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Medical Cannabis", "", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Recreational Cannabis (hashish/marijuana)", "", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Ecstasy", "", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Cocaine", "", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["", "Heroin", "", "", "o\u2081", "", "o\u2082", "o\u2083", "", "o\u2084"], ["If all options are marked with \u2018 Never\u2019 (=4), go to question DS.1", "", "", "", "", "", "", "", "", ""], ["CN.2 How old were you when you took any of the substances for the first time? (Tick one box PER ROW)", "", "", "", "", "", "", "", "", ""], ["", "", "Under", "10-14", "15-19", "20-24", "25-29", "30-34", "35 years", ""], ["", "", "10 years", "years", "years", "years", "years", "years", "and over", "Never"], ["", "Tranquilisers/Sedatives with a doctor\u2019s prescription", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Tranquilisers/Sedatives without a doctor\u2019s prescription", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Medical Cannabis", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Recreational Cannabis (hashish/marijuana)", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Ecstasy", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Cocaine", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"], ["", "Heroin", "o\u2081", "o\u2082", "o\u2083", "o\u2084", "o\u2085", "o\u2086", "o\u2087", "o\u2088"]]}, {"caption": "Table 4: Your answers are to remain confidential", "header": ["OP.1 During the 12 months, approximately how much did you pay out-of-pocket for dental care which was foryour own need? (Tick one box ONLY)Amount \u20ac ____________________________________________________________  o\u2081Does not apply                                           o\u2082"], "rows": [["OP.2 During the past 4 weeks, approximately how much did you pay out-of-pocket for private visits toGPs/family doctors which were for your own care? (Tick one box ONLY)Amount \u20ac ____________________________________________________________  o\u2081Does not apply                                           o\u2082"], ["OP.3 During the past 4 weeks, approximately how much did you pay out-of-pocket for private visits tomedical/surgical specialists which were for your own care? (Tick one box ONLY)Amount \u20ac ____________________________________________________________  o\u2081Does not apply                                           o\u2082"], ["OP.4 During the past two weeks, approximately how much did you pay out-of-pocket for medicines which wereprescribed by a doctor for your own use? (Tick one box ONLY)Amount \u20ac ____________________________________________________________  o\u2081Does not apply                                           o\u2082"], ["OP.5 During the past 4 weeks, approximately how much did you pay out-of-pocket for visits to other healthcareprofessionals which were for your own care? (Tick one box ONLY)E.g. physiotherapists and occupational therapistsAmount \u20ac ____________________________________________________________  o\u2081Does not apply                                           o\u2082"], ["INCOME"], ["IN.1 Do you know what is your household\u2019s total net income per month from all the sources after deductionsfor income tax and National insurance? (Tick one box ONLY)Thisincludesall the income earned by you and other household members.The total is the amount left after tax, National Insurance etc. have been deducted.Yes (Specify amount) \u20ac _______________________________________   o\u2081\u2192 End of questionnaireNo                                          o\u2082"], ["IN.2 Can you give an indication of the amount? (Tick one box ONLY)Below \u20ac996                                     o\u2081Between \u20ac996 and \u20ac1565                             o\u2082Between \u20ac1,566 and \u20ac2,307                            o\u2083Between \u20ac2,308 and \u20ac3,300                            o\u2084Above \u20ac3,300                                    o\u2085Do not know                                    o\u2086"]]}]}