Housemate Survey Name______Age______Date______These questions may help find a housemate for you with similar interests. If you cannot answer the questions yourself, someone who knows you well can help. If someone helps you, the following information should be supplied: Assistance provided by ______Phone ______Relationship ______E-mail______
General Information I would like to live in the following location? (If there is a specific location, list it.) City ______1. Small Town ______ In the Country ______I already know someone I’d like to have for a housemate. That person’s name is 2. ______.
I communicate by ______3. ______
I would rather live with people who are of the My gender is: same gender. 4. Male The gender of my housemate doesn’t matter to Female me. A housemate would need to I could not live with someone who is: know this about my lifestyle: ______5. ______
I prefer to live with someone whose age is close to mine. 6. The age of my house-mate doesn’t matter to me. Yes If yes, what kind of pet? ______7. I would like a pet in the house. No If no, are certain pets ok (I.E. fish) ______ I smoke. I could live with someone who smokes as long as they did it outside. 8. I would not want to live with someone who smokes. I do not care if my housemate smokes I have the following health/physical issues that may impact the person I live with : ______9. ______
I have the following allergies (include food, medications or sensitivities [smells, perfumes, etc.] ) : ______10. ______
Additional Comments: Additional Comments:
Personal Traits & Behaviors Additional Comments: 1. Mark the words that describe you: Friendly Shy Loud Activities Happy & InterestsSad Quiet Additional Comments: 1. I enjoyI enjoy hugs playing from: video games. 2. ______2. ______I enjoy watching movies. If so, what type(s)? I ______am very concerned about cleanliness of my home/housemate. 3. (comedy, animation/Disney, scary, etc.) 3. HavingI enjoy a watchingclean home/housemate television. is notIf so,that what important shows? to ______me. I ______will share household responsibilities with my housemate. The chores I 4. 4. preferI am botheredto do are: by scary or violent movies, ______television shows, or video games. 5. ______I like to listen to music. If so, what type? When I get______upset, I ______5. ______ My feelings get hurt easily. 6. 6. I like to play music loudly. I like to help others. 7. 7. I like to participate in sports. If so, what type(s)? ______ I like to share my belongings with 8. ______others. I borrow things from others often. 9. 8. I like to play games. If so, what type? ______ I am bothered by profanity and 10. 9. cursing.I enjoy spending time outdoors. I would wantIf so, these what rules outdoor in my activities? home: ______11. ______My temperature preference is: Warm 12.10. Other hobbies I enjoy are Cool______ Don’t______Care
I usually stay at home during the day.
I usually spend the day away from home 11. (Describe what you do)______Additional Comments:
Eating Habits Additional Comments: 1. I can cook my own food.
2. I am willing to cook for my housemate.
3. I like to share food.
4. I do not like to share food.
5. I require a special diet. (Describe it): ______
Additional Comments:
Sleeping Habits Additional Comments: On week days (M-F) I generally like to wake 1. up at ______.
On week days I like to be in bed by ______. 2. On weekends I generally like to 3. wake up at ______.
On weekends I generally like to be 4. in bed by ______.
I get up during the night. 5. I snore. 6. I like to take naps. 7. Additional Comments:
Socialization Additional Comments:
I enjoy having guests visit in my home:
Every day. 1. Once a week. A couple of times a week. I prefer not having a lot of guests.
I like to attend religious services.
2. If so, what religion?______
How often do you like to attend religious activities? ______
I would like to spend time with my 3. housemate.
I would rather go out in the community for activities than stay home. 4. I would rather stay home than go out into the community for activities. When I go out , I like to: ______5. ______
Additional Comments: