Details of the host family: 1) Name and age of the host mother: 2) Her profession: 3) Hours she stays

away from home: 4) Name of the host father: 5) His profession: 6) Hours he stays away from home: 7) Do either of parents work : a) Yes b) No 8) Home address: 9) Number of children to be taken care of: 13) The language spoken at home: 14) Do the children speak any other language? If yes, please specify. a) Yes b) No 15) Do any of the family members have any physical or mental disability? If yes, please specify. a) Yes b) No 16) Does your family possess any special dietary habits? If yes, please specify. (for example: vegetarian dishes on certain days etc.) a) Yes b) No 17) Are there any pets in the household? If yes, please specify. a) Yes b) No highest level of education is: ____High School ____Attended College ____Undergraduate Degree ____Graduate School My annual household income is: ____Under $20,000 ____$20,000-$45,000 ____$45,000-$65,000 ____$65,000-$90,000 ____$90,000-$125,000 ____$125,000 plus

Sample Health History questionnaire for Personnel Training

Name: ______________________________________________ Address: ____________________________________________

Phone number: _______________________________________ Email address: ________________________________________ (Please tick in front of the right options wherever provided with choices) 1. Have you been critically ill in the past? a. Yes b. No 2. If yes, please specify the details of the illness ___________________________________ 3. Do you feel pain in your joints or bones while doing any physical activity? a. Yes b. No 4. Do you lose your balance or fall unconscious because of dizziness? a. Yes b. No 5. Have you had or presently suffer from any of the following medical situations? a. High blood pressure b. Low blood pressure c. Diabetes d. High cholesterol

e. Chest pains f. Pain, discomfort in the chest, neck jaw, arms, or other areas g. Unusual fatigue or shortness of breath with usual activities h. Others 6. Please specify other _______________________________________________________ 7. Are you on medication for any minor or major health issues? a. Yes b. No 8. Do you have history of health problems in your family? a. Yes b. No 9. If yes, then give details ____________________________________________________ 10. Please provide your following details a. Heightb. Weight11. Please list down your personal health and fitness objectives.