Survey Sheet

Food Adulteration And Its

Harmfull Effects.
Name:__________________________________
_______
Profession:______________________________
_______
No. of Family
Members:___________________
1.

Have you or any of your family members suffered from any of this
diseases?
Sl.no. NAME OF THE DISEASE
1

Cancer

Diarrhoea

Frequent joint pain

Stomach and liver disorders

Heart diseases

Tumour

Early loss of eyesight

Glucoma

YES/NO

1. How many days in a week you eat outside?

_______
2. From where do you bring your raw food materials:
a. Local grocery shop

________

b. Food marts

________

c. Ration shop

_________

d. Any other

_________

3. Do you check the food items whether it is adulterated

or not before buying?
___________
4. Have you ever personally seen food adulteration in a
factory or somewhere else or shopkeeper selling
adulterated food? If yes then where?
____________________________________________
____________________________________________
Are you or any of your known person is involved with
any adulteartion campaigns? If yes then which one?
____________________________________________

Signature.