<p> 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______</p><p>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. ______.</p><p>I communicate by ______3. ______</p><p> 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. ______</p><p> 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. ______</p><p>I have the following allergies (include food, medications or sensitivities [smells, perfumes, etc.] ) : ______10. ______</p><p>Additional Comments: Additional Comments:</p><p>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</p><p> I usually stay at home during the day.</p><p> I usually spend the day away from home 11. (Describe what you do)______Additional Comments:</p><p>Eating Habits Additional Comments: 1.  I can cook my own food.</p><p>2.  I am willing to cook for my housemate.</p><p>3.  I like to share food.</p><p>4.  I do not like to share food.</p><p>5.  I require a special diet. (Describe it): ______</p><p>Additional Comments:</p><p>Sleeping Habits Additional Comments: On week days (M-F) I generally like to wake 1. up at ______.</p><p>On week days I like to be in bed by ______. 2. On weekends I generally like to 3. wake up at ______.</p><p>On weekends I generally like to be 4. in bed by ______.</p><p> I get up during the night. 5.  I snore. 6.  I like to take naps. 7. Additional Comments:</p><p>Socialization Additional Comments:</p><p>I enjoy having guests visit in my home:</p><p> Every day. 1.  Once a week.  A couple of times a week.  I prefer not having a lot of guests.</p><p> I like to attend religious services.</p><p>2. If so, what religion?______</p><p>How often do you like to attend religious activities? ______</p><p> I would like to spend time with my 3. housemate.</p><p> 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. ______</p><p>Additional Comments:</p>