Personal Hygiene Survey

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0

Name
0

Date of birth
0

Gender
0

Occupation
0

Rate how frequently you participate in the following hygiene habits:

Never

Frequently

Washing hands before eating

Never

Frequently

1 Never

2

3

4

5 Frequently

Washing hands after using the toilet

Never

Frequently

1 Never

2

3

4

5 Frequently

Using hand sanitizer

Never

Frequently

1 Never

2

3

4

5 Frequently

Wearing washed clothes

Never

Frequently

1 Never

2

3

4

5 Frequently

Walking outside barefoot

Never

Frequently

1 Never

2

3

4

5 Frequently

Drinking clean, safe drinking water

Never

Frequently

1 Never

2

3

4

5 Frequently
0

How regularly do you shower?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

What type of soap do you use?
0

How regularly do you brush your teeth?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

How regularly do you floss?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

When do you wash your hands during the day? Check all that apply.
When preparing food

Before eating

When caring for the sick

When treating wounds

After using the toilet

When coughing or sneezing

When handling animals

After touching garbage
0

How often do you clean the house?
Never

Rarely

Monthly

Weekly

Daily
0

How often do you dispose of trash ?
Never

Rarely

Monthly

Weekly

Daily

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0

Name
0

Date of birth
0

Gender
0

Occupation
0

Rate how frequently you participate in the following hygiene habits:

Never

Frequently

Washing hands before eating

Never

Frequently

1 Never

2

3

4

5 Frequently

Washing hands after using the toilet

Never

Frequently

1 Never

2

3

4

5 Frequently

Using hand sanitizer

Never

Frequently

1 Never

2

3

4

5 Frequently

Wearing washed clothes

Never

Frequently

1 Never

2

3

4

5 Frequently

Walking outside barefoot

Never

Frequently

1 Never

2

3

4

5 Frequently

Drinking clean, safe drinking water

Never

Frequently

1 Never

2

3

4

5 Frequently
0

How regularly do you shower?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

What type of soap do you use?
0

How regularly do you brush your teeth?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

How regularly do you floss?
Never

Monthly

1-3 times a week

4-6 times a week

Daily
0

When do you wash your hands during the day? Check all that apply.
When preparing food

Before eating

When caring for the sick

When treating wounds

After using the toilet

When coughing or sneezing

When handling animals

After touching garbage
0

How often do you clean the house?
Never

Rarely

Monthly

Weekly

Daily
0

How often do you dispose of trash ?
Never

Rarely

Monthly

Weekly

Daily