Common Household Remedies and MedicinesParent Survey

Name: ______________________ Block: ________

Please ask your parents to complete the following survey. DUE NEXT LESSON.Question 1For each statement circle a number 1-5 which indicates whether you strongly agree (5), agree (4), no opinion (3), disagree (2) or strongly disagree (1).

1. We use medications regularly 1 2 3 4 5

2. We prefer to use preventative health care 1 2 3 4 5

3. We regularly take multivitamins 1 2 3 4 5

4. We use herbal/natural remedies for illnesses 1 2 3 4 5

Question 2What is the most commonly used medication for your family? __________________________

Question 3Please rank the most common illness to the least common illness in your house 9 = most common, 1 = least common. You can give several illnesses the same rank if they are the same importance.

Ailment Please rank the following itemsHeadacheCold/FluFeverStomach AcheToothacheRashSore ThroatEye IrritationEarache

Question 4Please rank the most common treatment to the least common treatment used in your house. 6 = most common, 1 = least common. You can give several treatments the same rank if they are the same importance.

Treatment Please rank the following itemsBed RestMultivitaminsAntibioticsLiquidsNutritionMedicines (OTC)Other