Male Female I am: Single Married Engaged Divorced Other



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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 safety other:



If I would be 10 mins. late for class because I forgot my cell phone, I would: get it get my messages later



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