General Questions/Academics (Unless otherwise specified, when items are presented in bold, circle all items that apply)
My age:_____
I am: Male Female
I am: Single Married Engaged Divorced Other:
My class:
Freshman
Sophomore
Junior
Senior
Graduate
Univ. Coll.
My hometown: Rural
Urban
Mixed
I own a cell phone: No Yes How long?
I live: (circle one) In a Dorm On campus Apt. Off campus Apt. w/Parents Other:
I am in a Fraternity or Sorority : Yes No
I am an athlete: Varsity
Club Sport
Intra-murals
I have a job during the school year: Yes No If “Yes”, I work
hours per week (on average).
The “social class” I believe my family would fit into is: Lower Lower-Middle Middle Upper-Middle Upper
How many hours a week during the school year, on average, I spend studying?
How many hours a week during the school year, on average, I spend reading?
How many hours a week during the summer I spend reading?
High School GPA:
Current GPA:
Last semester’s GPA:
SAT Total:
How many nights do you go out each week?
How many nights do you drink alcohol each week?
How many classes do you choose not to attend each week
Have you ever been put on academic probation? Yes No
How often do you study while listening to music: Never 1-2x/week 3-4x/week 5+x/week Always
On a scale of 1-10 (with 10 being representing “always” and 1 representing “never”), answer the following questions:
My grades reflect the effort I put into my schoolwork
I struggle to pay attention in my classes
I feel fatigue or lack of sleep affects me during class
My sleep habits affect my overall GPA
I prefer to study in silence
I remember what I read when listening to music and studying
Listening to music while studying positively influences my grades
Being in a fraternity negatively affects grades
Being in a sorority negatively affects grades
Being an athlete negatively affects grades
I have attended a class while drunk
Alcohol
I consume alcohol: Daily Weekly Monthly Every 6 months Yearly
Never (circle all that apply)
I first consumed alcohol at the age of:
My first drink was give to me by:
I drink with: friends
siblings
parents alone
Biggest influence on my drinking
On average, when I consume alcohol, I usually have
(fill in number)
(fill in type of drink)
At a party, when I consume alcohol, I usually have
(fill in number)
(fill in type of drink)
I drink because:
stress relief
fun
social reasons
other
Due to drinking, I have skipped class the next morning
No Yes (how many times a semester?)
Due to drinking, I have missed/handed in late assignments No Yes (how many times a semester?)
I have drank the night before I had an early class (i.e., before 10 AM) No Yes Before an exam?
No Yes
Someone in my family has been diagnosed with alcoholism? Yes No
If yes, check any or all relatives who have been diagnosed with alcoholism:
mother
father
grandmother
grandfather
sibling(s)
twin
other (specify):
How many drinks per week, on average, does your mother consume?
Your father?
Drugs, Caffeine, & Smoking:
I Smoke(d) cigarettes: Daily
Weekly Monthly Every 6 months Yearly Once/few times Never did
Age first smoked a cigarette:
First given to me by:
My brand is:
Do your parents smoke? Mother Father Both
Biggest influence on my smoking
I smoke
cigarettes, on average, each day
I will quit one day? Yes No When?
If you smoke and plan to quit, why have you not quit yet? stress school tried but failed other:
I do not smoke regularly, but I smoke when I drink alcohol? Yes No When I drink caffeine? Yes No
I smoke cigarettes mostly in the:
Morning
Afternoon
Evening
Late Evening
I smoke for: stress relief
weight control
addicted social reasons
self image other:
After smoking a cigarette, I feel: Relaxed
calm
sick tense relief
other:
I drink caffeinated beverages:
Daily
Weekly
Monthly Never How many drinks per day?
I drink caffeinated beverages mostly in the:
Morning
Afternoon
Evening
Late Evening
Amount of caffeinated beverages I drink per day (in fluid oz.): coffee
tea
soda
other
I Smoke(d) marijuana: Daily
Weekly Monthly Every 6 months Yearly Once/few times Never did
Age first smoked marijuana:
First given to me by:
I smoke alone: No Yes (how often?)
How many days a week do you smoke?
I have gone to class high Yes No
I have missed class because I was high Yes No
How often does smoking marijuana result in late or not turning in homework or assignments?
I Use(d) other drugs:
Daily
Weekly Monthly Every 6 months Yearly Once/few times Never did
Age first used other drugs:
First given to me by:
On a scale of 1-10 (with 10 being the most representative of your beliefs), answer the following questions:
If you use drugs or alcohol regularly, have become less motivated in your academic performance
Regular drug or alcohol use affects one's memory
After a few drinks, I feel more comfortable talking to people
After a few drinks, I feel more attractive
After a few drinks, I feel more connected with others
Male college students drink more than female college students
I drink more than the average college student
I smoke marijuana more than the average college student
The average college athlete drinks more than the average college student
The average college student drinks more than their average non-college-attending peer
The average college student smokes marijuana more than their average non-college-attending peer
The average college fraternity member drinks more than the average college student
The average college sorority member drinks more than the average college student
High school athletes drink more than high school non-athletes.
College athletes drink more than college students in fraternities/sororities.
Prevention programs can help decrease binge drinking
…can help decrease smoking marijuana
Students misperceived the drinking habits of their peers
…the marijuana smoking habits of their peers
Cigarette smoking affects athletic ability (in general, not while actually involved in athletics)
Drinking alcohol affects athletic ability (in general, not while actually involved in athletics)
Smoking marijuana affects athletic ability (in general, not while actually involved in athletics)
Using other recreational drugs affects athletic ability (in general, not while actually involved in athletics)
Smoking cigarettes relieves feelings of stress or anxiety
I get headaches if I do not consume a certain amount of caffeine each day
I get tired if I do not consume a certain amount of caffeine each day
Weight gain is a concern when people quit smoking
People replace cigs. with food when they quit smoking
Who is more likely to be concerned with weight gain after they quit smoking: males females
Relationships
I am currently in a relationship:
Yes No
How long? (in months)
Is this a long-distance relationship?
Yes No
Distance? (in miles)
(in hours)?
Is this a monogamous relationship
Yes No
Is this a sexual relationship
Yes No
If monogamous, have you "cheated" (ie, been "intimately involved" with someone else)? Yes No
If monogamous, have you "been cheated on"? Yes No
How often do you see your “partner”?
How many times (in this relationship)?
Did you tell your partner you cheated? Yes No
How many previous relationships have you had?
How many were monogamous?
In how many of these previous did you "cheat"?
In how many did you admit you cheated?
If long distance, how do you communicate: phone
IM
e-mail
text msg
If in a relationship, do you drink or use drugs together?: Yes No
On a scale of 1-10 (with 1 being “not cheating” and 10 being “definitely cheating”), answer the following questions
Taking someone out on a date while in a relationship, but with no physical contact.
Taking someone out on a date while in a relationship and kissing them at the end of the night.
Hooking up (defined as kissing or more) with someone else while in a relationship.
Hooking up with someone else while in a relationship, but under the influence of alcohol or drugs.
Telling another person that you “like” them (have romantic feelings for them) while in a relationship.
Based on the scenarios you saw as “cheating,” have you been cheated on? Yes No Have you ever cheated? Yes No
If you were cheated on, how did it make you feel (1-10 with 10 being “devastated” and 1 being “no effect”)
On a scale of 1-10 (with 1 being “strongly disagree” and 10 being “strongly agree”), answer the following questions
I am satisfied with my current relationship
I am in an “open” relationship
My feelings towards my partner have changed for the positive since being involved in this relationship
I become more jealous as I become more attached to someone
I would consider being in another long-distance relationship (if in one)
I would consider being in a long-distance relationship (if never been in one)
School and extracurricular activities get in the way of a long-distance relationship
I get jealous when my partner in a long distance relationship goes out socially with friends
I am emotionally attached to my partner
I am jealous in my relationship
Jealousy comes from too much attachment
Jealousy comes from bad experiences with a partner
Jealousy comes from a partner lying or cheating
Jealousy comes from personal insecurity or mistrust
On a scale of 1-10, rank the following skills crucial to a long-relationship
Trust
Patience
Communication
Minority Issues On a scale of 1-10 (with 10 being the most representative), answer the following questions:
I prefer living in an urban area, more than a suburban area, based on multicultural aspects
Minority students are unaccounted for at SJU
Interracial relationships are valued in society
Every ethnic group can be discriminated against
Objects of discrimination often exaggerate the issue
If I was involved in a relationship with a partner of a different ethnic group, I would let them meet my parents
Sleep Habits
Do you experience any of the following sleep problems, and how often: (circle one for each)
Difficulty falling asleep
Never
<1x per week
2-3x a week
4+x a week
Insomnia
Never
<1x per week
2-3x a week
4+x a week
Nighttime awakenings
Never
<1x per week
2-3x a week
4+x a week
Difficulty waking (morning)
Never
<1x per week
2-3x a week
4+x a week
During the week: Average time do you go to bed?
Wake up?
Est, # of hours slept per night
During the weekend: Ave. time do you go to bed?
Wake up?
Est, # of hours slept per night
On a scale of 1-10 (with 10 being the most representative of your feelings), answer the following questions
I sleep well during the week
I sleep well during the weekend
I get enough sleep
In the past two weeks, indicate the number of times you have:
Remembered dreaming
Had nightmares
remembered details from dreams
Could not fall asleep
Could not fall asleep due to stress
Body Image/Health
How many days a week do you exercise?
How many hours per week, on average, do you exercise?
Rate the quality of your exercise:
Light (ex: walking)
Moderate (ex: jogging)
Heavy (ex: running)
On a scale of 1-10 (with 10 being the most representative of your feelings), answer the following questions:
I am overweight
I am underweight
I am average weight
I am confident in myself
My weight is a primary concern in my daily life
I actively maintain my weight
On a scale of 1-10 (with 10 being the most satisfied), rate your satisfaction with your:
Weight
Height
Face
Stomach
Legs
Hips
Butt
Body shape
In the past two weeks, indicate if you have experienced any of the following issues or conditions:
Common cold
nervousness
headaches
migraines
depression
change in appetite
weight change
insomnia
anger
back pain
stress
fatigue
Mood
On a scale of 1-10 (with 10 being the most representative of your feelings), answer the following questions:
I am affected by peer pressure
My daily mood is a positive one
The opinions of my parent(s) (or guardian) about my grades effect how I feel about my grades
I am negatively affected by bad grades
I am positively affected by good grades
My mood is affected by problems in my romantic relationship (if applicable)
My mood is affected when my romantic relationship is going well (if applicable)
My mood is affected when my romantic partner does not return my call/IM/text message (if applicable)
My mood is affected by my stress level
My mood is affected by family problems
My mood is affected by hunger
My mood is affected by money issues
I am anxious on a daily basis
School causes me to feel anxious
Relationships cause me to feel anxious
My family cause me to feel anxious
My friends cause me to feel anxious
I have been diagnosed with depression
Career/Major
My Major:
Have you changed majors? No Yes (How many times?)
My intended career or profession:
My Father's profession:
My Mother's profession:
The highest degree I plan on receiving: MA/MS Ph.D./Psy.D. M.D. J.D. (Law) MBA Other:
On a scale of 1-10 (with 1 being “not confident” and 10 being “definitely confident”), answer the following questions
My major is the right one for me
I will not change my major
Cell Phone Use (the following questions pertain only to cellular phone use, not traditional “land lines”)
How old were you when you first had a cell phone?
How many cell phones in your family?
How many calls do you make daily?
How many calls do you receive daily?
How many text msgs. do you make daily?
How many text msgs. do you receive daily?
I initially got a cell phone for:
job/school
my friends had one
If I would be 10 mins. late for class because I forgot my cell phone, I would:
safety
get it
other:
get my messages later