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Household Member Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

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1

What is the complete name of the household member?

Please provide the full name of the household member.
2

Relationship to you

Select the relationship of the household member to you.
3

Age of the household member

Please rate the age of the household member.
4

Gender of the household member

Please provide the gender of the household member.
5

Occupation of the household member

Please indicate the occupation of the household member.
6

Education level of the household member

Select the highest education level attained by the household member.
7

Annual income of the household member

Please rate the annual income of the household member.
8

Health condition

Select the general health condition of the household member.
9

Hobbies/Interests

Please list the hobbies or interests of the household member.
10

Any additional information

Is there anything else you would like to share about the household member?
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