This document contains a survey for parents about common household remedies and medicines. It asks parents to rate how much they agree with statements about medication and health care use and to rank common illnesses and treatments. Parents are asked to provide information on the most commonly used medication in their family as well as to rank order common ailments and treatments from most to least common. The survey aims to gather data on typical health care practices in the home.

1. Common Household Remedies and Medicines
Parent Survey
Name: ______________________ Block: ________
Please ask your parents to complete the following survey.DUE NEXT LESSON.
Question 1
For 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 2
What is the most commonly used medication for your family? __________________________
Question 3
Please rank the most common illness to the least common illness in your house9 =most common, 1= least
common. You can give several illnesses the same rank if they are the same importance.
Ailment Please rank the following items
Headache
Cold/Flu
Fever
Stomach Ache
Toothache
Rash
Sore Throat
Eye Irritation
Earache
Question 4
Please 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 items
Bed Rest
Multivitamins
Antibiotics
Liquids
Nutrition
Medicines (OTC)
Other