Antibiotic Use Survey

A public-health survey that looks at household antibiotic use patterns to help spot risks tied to antibiotic resistance.

Use this template

Age

Gender

1.1 Which of the following medications are antibiotics?

Amoxicillin Ibuprofen Azithromycin Paracetamol/Acetaminophen Ciprofloxacin

1.2 Have you ever taken antibiotics?

Yes No

1.3 How many times have you taken antibiotics during the past 12 months?

0 times 1-2 times 3-5 times 6 or more times

1.4 How many times has another adult in your household (over 18 years old) taken antibiotics during the past 12 months?

0 times 1-2 times 3-5 times 6 or more times

1.5 How many children under the age of 18 live in your household on a regular basis?

0 1 2 3 or more

1.6 How many times have children in your household received antibiotics during the past 12 months (in total)?

0 times 1-2 times 3-5 times 6 or more times

1.7 Is anyone in your household taking antibiotics at the moment?

Yes No

1.8 If yes, for what reason?

	Column 1	Column 2	Column 3
Row 1
Row 2

	Column 1	Column 2	Column 3
Row 1
Row 2

	Column 1	Column 2	Column 3
Row 1
Row 2

	Column 1	Column 2	Column 3
Row 1
Row 2

Related templates