(c) Ruth C. Engs, Bloomington, In. 1992. There is NO charge for the use of this questionnaire. Students doing research for classroom projects do not need to get permission to use the questionnarie. Others please contact me by email: Add engs to "at sign symbol" to indiana.edu and put in your emailer. Dr. Ruth C. Engs, Poplars 615, Indiana University, Bloomington, IN 47405.
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)? __________