Please do not put your name on this questionnaire as we wish to retain your anonymity. Please put on the line a code name known only to you (examples: your grandmother's maiden name, your dog or favorite movie actor, etc.)
Check the following items which apply to you:
Sex: _____ Male _____ Female
Age: _____
Race: _____ White _____ Black _____ Hispanic _____ NA Indian
_____ Asian _____ Other
Living arrangements: _____ Off Campus without parents _____ On Campus
_____ Off campus with parents
Health Problems
On the line beside each health problem write in how many times you have experienced
it OVER THE PAST MONTH.
(Note: If you experience it just about every day this would be about 28, about twice a
week would be equal to 8, one a week 4, once a month 1, not at all leave blank.)
_____ headache
_____ ear infection
_____ eye infection
_____ sinus infection
_____ nose bleeds
_____ bronchitis or laryngitis
_____ pneumonia
_____ cough
_____ a "cold" or the flu
_____ sore-throat
_____ "mono"
_____ acne flair-up
_____ hay fever/asthma flair-up
_____ bleeding gums
_____ tooth abscess
_____ stomach upset
_____ nausea or vomiting
_____ ulcer
_____ diarrhea
_____ high blood pressure
_____ muscle strain
_____ a sprain
_____ a broken bone
_____ cut or hurt myself so that I needed to see a doctor
_____ lack of energy
Other health problem (write in)
______________________________________________
Women only:
_____ menstrual irregularity
_____ menstrual cramps
_____ vaginal yeast infection
_____ other kind of vaginal infection
_____ bladder/urinary tract infection
_____ sexually transmitted disease
Write in which ones.
_________________________________________________
Men only:
_____ burning on urination
_____ urinary tract infection
_____ sexually transmitted disease
Write in which ones.
_________________________________________________
Health related problems over the past month for all students
1. Over the past month how many times have you visited a doctor or the student
health service because you were sick? __________
2. How many times have you missed class or other commitment because you were
sick during the past month? __________
3. How many courses of antibiotics have you taken during the past month?
_______
Lifestyle habits over the past month
1. How many times did you exercise during the past month? __________
2. When you exercised, on the average how many minutes did you engage in the
exercise? __________
3. How many times did you feel "stressed out" (under stress) during the past
month? __________
4. When you felt stressed out how many hours did it usually last? __________
5. How many times did you feel angry or irritated during the past month?
_________
6. When you felt angry or irritated how many hours did it usually last? __________
7. Over the past month how many times did you feel depressed? __________
8. When you felt depressed how many hours did it last? __________
9. During the past month how many times did you drink beer? Please circle.
a. every day
b. two or three times a week
c. once a week
d. at least once a month but less than once a week
e. not at all
10. When you drank beer how many average size glasses or cans did you usually
consume at any one sitting? __________
11. During the past month circle how many times you drank wine or a wine cooler.
a. every day
b. two or three times a week
c. once a week
d. at least one a month but less than once a week
e. not at all
12. When you drank wine how many average size glasses or small bottles of wine
coolers did you usually consume at any one sitting? __________
13. During the past month how many times did you drink a hard liquor (vodka, rum,
whiskey, etc.)? Please circle.
a. every day
b. two or three times a week
c. once a week
d. at least once a month but less than once a week
e. not at all
14. When you drank liquor how many shot glasses or shots in mixed drinks did you
usually consume at any one sitting? __________
15. During the past month how many days did you use tobacco? __________
16. How many cigarettes did you smoke on the days you smoked? __________
17. How many dips of chewing tobacco/snuff did you use on days you used it?
__________
18. How many days did you smoke marijuana during the past month? __________
19. How many joints did you smoke on the days you used marijuana? __________
20. How many days did you binge out on food? __________
21. On the days you binged out on food how many times did you purge (vomit or use
laxative)? __________