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College of Nursing
Please answer the following questions as honestly as you can, put a check on the
appropriate boxes that correspond to your answer.
B. ENVIRONMENTAL FACTORS
Please put a check () on the appropriate boxes that correspond to your answer.
How do you rate the following factors regarding their contribution towards good health?
A. WORKING FACILITIES:
D. WATER SUPPLY:
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E. TOILET FACILITY:
G. DRAINAGE SYSTEMS:
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2. Do you have any history of any hereditary diseases (self and family members)?
Yes No
If YES, please check appropriate box/es below:
Yes No
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