PROFORMA

CLASS/STD-
ROLL NO-

Name of the SCHOOL-

1) Communicable diseases are caused by Germs

Yes / No / Don’t know

2) Germs grow in wet and dirty places

Yes / No / Don’t know

3) Germs can spread through air

Yes / No / Don’t know

4) Germs can spread through insects

Yes / No / Don’t know

5) Germs cannot spread through food or water

Yes / No / Don’t know

6) Do you think boiling and filtering drinking water will kill the germs present in it?

Yes / No / Don’t know

7) Flies and Cockroaches carry germs from dirty places and can contaminate our food &
water

Yes / No / Don’t know

8) Passing urine/ stools outside the Latrine is harmful to you and others health?

Yes / No / Don’t know

9) Do you wash your hands with soap after using the toilet?

Yes / No

10) Do you wash your hands with soap before eating?

Yes / No

1
11) Do you wash your hands & feet with soap after going to your house/ room from your
classroom or school?

Yes / No

12) When the flush in the toilet does not work, do you fill water in bucket and pour it in
toilet?

Yes / No

13) Do you flush the toilet when you find the previous user has not done it?

Yes / No

14) Sneezing / coughing can spread flu germs

Yes / No / Don’t know

15) Do you carry your own handkerchief every day?

Yes / No

16) When somebody sneezes or coughs in front of you, do you cover your nose & mouth
with handkerchief?

Yes / No

17) Do you use dustbin to throw used wrappers/ papers/ covers?

Yes / No

18) When you eat chocolate, do you throw the wrapper on the floor/road, if you don’t find
the dustbin?

Yes / No

19) Will you clean the room if someone else has made it dirty?

Yes / No

20) Hand washing can prevent the spread of the diseases

Yes / No / Don’t know

21) If your friend has cold/ cough will you share your things with him/ her?

Yes / No / Don’t know

22) Do you take bath daily with soap?

Yes / No / Don’t know

23) How often do you wash your hair?

2
 _____________

24) How many times do you brush your teeth in a day?

Once / Twice / More than two times

25) Do you cut your nails regularly?

Yes / No

26) What kind of food we should eat?

Covered food / Uncovered food

27) What type of food should we eat?

Healthy food / Fast food

28) Eating fried and oily food items regularly is good for health

Yes / No / Don’t know

29) How often do you eat fast food items?

Once a week/ Once in a month/ Regularly

30) In order to keep yourself fit & healthy you need to do regular / daily exercises

Yes / No / Don’t know

31) Exercise helps in growing taller and stronger

Yes / No / Don’t know

32) Children must always study and should not play

Yes / No / Don’t know

33) Playing outdoors is not a form of Exercise

Yes / No / Don’t know

34) Children cannot practice YOGA

Yes / No / Don’t know

35) How many hours you spend on activities other than studies

______hours

36) Do you participate in the cultural and sports events conducted by the school?

Yes / No

3
37) How many times in last three months you suffered from loose motions?

-------------------

38) How many times in last three months you suffered from fever /cold / cough?

--------------------

39) Do you think air pollution is harmful to our health?

Yes / No

40) How can we reduce air pollution?

By planting more trees / Increasing use of vehicles