(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)? __________