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Short Health Survey

This short survey is completely voluntary and anonymous. None of the information provided by you will ever, in any way, be correlated with your actual identity. No one knows who you are and no one is trying to kill you. The data from this form will be used as the basis for an undergraduate research paper that is designed to help better understand the effects of sleep and illness on academic performance. By completing this survey, you are performing an outstanding service to your fellow man! Future generations of students depend on you, so please make your entries as honest and accurate as possible, and please, only submit one completed survey per person.

Basic Information

Gender

Male
Female
Other

If other please specify:

Age

18
19
20
21
22
23
24
25

Major(s) Studied

Cumulative GPA

Sleeping Patterns

Since your enrollment in college, about how many hours of sleep do you get per night during the academic year?

Greater than 12 hours
Between 8 and 12 hours
Between 7 and 8 hours
Between 5 and 7 hours
between 2 and 5 hours
Fewer than 2 hours
"No rest for the wicked!!!!" >: D

Do you typcially make up for sleep lost during the week on the weekends?

Yes
No
Sometimes

How many times do you wake from sleep during a typcial night?

Greater than 10 times
Between 6 and 10 times
Between 4 and 6 times
Between 2 and 4 times
Fewer than 2 times
Never

Have you ever been diagnosed with a chronic sleeping disorder? (ex: insomnia, sleep apnea, narcolepsy)

No
Not sure
Yes

If yes, please specify:

Illness

Since your enrollment in college, about how many times in an academic year do you experience cold, flu, or other symptoms of illness?

"Move over Typhoid Mary!!!" >: D
Greater than 10 times
Between 6 and 10 times
Between 4 and 6 times
Between 2 and times
Fewer than 2 times
"Unbreakable"

Additional Comments:

How many times per term do you typically miss class?

Roughly how many of those absences are due to illness?

Diet and Activity Patterns

Do you excercise regularly? (At least three times a week for at least 20 minutes per session)

Yes
No

On average, how many caffeinated beverages do you consume on a daily basis?

"I drink coffee to negative the effects of my medication..."
Greater than 10
Between 6 and 10
Between 4 and 6
Between 2 and 4
Fewer than 2
"Decaf, thanks."

On average, how many alcoholic beverages do you consume per week?

"Certified lush"
Greater than 10
Between 6 and 10
Between 4 and 6
Between 2 and 4
Fewer than 2
None

Do you use illicit substances?

Yes
No

Which do you use?

Cocaine

Marijuana

Heroine

Methamphetamines

Other Please specify:

And how frequently do you use them?

Anually
Monthly
Weekly
Daily
Hourly

Medical Background

Do you recieve an annual flu vaccine?

yes
no

Do you have an immune-compromising medical condition, or are you taking medications that impair your immune system? (steroids, immunosuppressive drugs, chemotherapy drugs)

yes
no
maybe

If yes, please explain:

Yay, all done!!!! Now that wasn't soo bad, was it? My sincerest thanks for your participation!