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Men’s Health Survey
This form pertains to a medical and ethical issue that may be considered sensitive; however, this survey is anonymous and no personal information is recorded.
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* Indicates required question
How old are you?
*
Under 18
18-24
25-34
35-44
45-54
55+
Country of Birth
*
Your answer
What religion do you follow/practice?
Christianity
Judaism
Islam
Hinduism
Buddhism
Agnosticism/Atheism
Other:
Clear selection
Have you undergone surgical circumcision?
*
Yes, as an infant
Yes, as a child/adolescent
Yes, as an adult
No
Reason for Circumcision
Family/Religious/Cultural Purposes
Personal Hygiene
Preventative Healthcare
Unknown
Other:
Clear selection
Being circumcised is part of your religious/cultural identity
Yes
No
No, I am not circumcised
No, I have undergone circumcision for another reason
Clear selection
Do you think an individual’s consent should be required prior to circumcision?
*
Yes
No
Why or why not?
*
Your answer
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