Use the following numbers to fill out your degree of concern for yourself or others in terms of physical, mental and social health for the following items:

A. Not Concerned B. Mildly Concerned C. Moderately Concerned D. Very Concerned E. Extremely Concerned

_____ 1. Acne

_____ 2. Airplane Accidents

_____ 3. Air Pollution

_____ 4. Accidents Due To Electric Current

_____ 5. Alcohol Dependence

_____ 6. Nuclear Warfare

_____ 7. Auto Accidents

_____ 8. Biological and Chemical Warfare

_____ 9. Birth Control

_____ 10. Being Burned

_____ 11. "Colds"

_____ 12. Cancer

_____ 13. Childbirth

_____ 14. Death

_____ 15. Drowning

_____ 16. Drug Abuse

_____ 17. Headaches

_____ 18. Sexually Transmitted Disease Other Than AIDS

_____ 19. Eye Disorders And Blindness

_____ 20. Emphysema or Respiratory Disease

_____ 21. Firearm Accidents

_____ 22. Heart Disease

_____ 23. Halitosis (Bad Breath) Or Body Odor

_____ 24. Homosexuality

_____ 25. Kidney Diseases

_____ 26. Liver Diseases

_____ 27. Masturbation

_____ 28. Mental Illness

_____ 29. Moodiness

_____ 30. Mononucleosis ("Mono")

_____ 31. Nausea

_____ 32. Nervousness

_____ 33. Combat

_____ 34. What I'll Be Like In 10 or 15 Years

_____ 35. Overweight

_____ 36. Poor Teeth Decay

_____ 37. Population Explosion

_____ 38. Pregnancy

_____ 39. Sex Behavior

_____ 40. Poisoning By Snakes

_____ 41. Radiation

_____ 42. Riots

_____ 43. Smoking And Disease

_____ 44. Starvation And Malnutrition

_____ 45. Sterility

_____ 46. Suicide

_____ 47. Tuberculosis ("TB")

_____ 48. Use Of Contraceptives

_____ 49. Water Pollution Pollution

_____ 50. AIDS

____________________

Please contact me for permission to use the HCQ if you are not a student using it for school or university research projects. Email: Add engs to "at sign symbol" to indiana.edu in your emailer. There is NO charge for the use of any of my questionnaires. Feel free to arrange the items so they fit on one sheet of paper. My HTML editor does not allow me to do this.