STUDENT HEALTH and LIFESTYLE QUESTIONNAIRE

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(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)? __________