DOC

DESCRIPTIVE DATA

By Matthew Flores,2014-12-03 16:56
8 views 0
DESCRIPTIVE DATA 1- How old are you? : __________ 2- What is your gender? : _________ 3- What is your current country of residence?: _________ 4- What is the language you speak? : a. More often: _____________ b. At home:_________________ c. With friends:______________ 5- Indicate your current level of education? (Please highlight a..

    DESCRIPTIVE DATA

1- How old are you? : __________

2- What is your gender? : _________

    3- What is your current country of residence?: _________

4- What is the language you speak? :

    a. More often: _____________

    b. At home:_________________

    c. With friends:______________

5- Indicate your current level of education? (Please highlight answer.)

    a. High school

    b. Technical school/Training

    c. Undergraduate

    d. Masters, PhD

    e. Other, please specify:_____________

6- Are you presently studying? If your answer is “no”, skip to question 7. (Please

    highlight answer.)

    a. Yes

    b. No

    7- In what field do you presently study?

    ________________________________________________________

    8- Do you work? (Please highlight answer.)

    a. Yes

    b. No

9- If you answered “yes”, what is your position? : _________________________

    a. How many hours do you work per week? : __________ per week

    10- Who do you live with? (Please highlight answer.)

    a. Friend(s)

    b. Roommate(s)

    c. Kid(s)

    d. Girlfriend/boyfriend

    e. Parent(s)

    f. Sibling(s)

    g. Alone

    h. Other, please specify:_______

    11- What is your religion? : __________________

    If no religion beliefs, skip the next 2 questions

12- What is your level of belief in this religion? (Please highlight answer.)

    a. very low

    b. low

    c. average

    d. high

    e. very high

13- What is your level of practice of this religion? (Please highlight answer.)

    a. very low

    b. low

    c. average

    d. high

    e. very high

14- How would you define your general level of health? (Please highlight answer.)

    a. very bad

    b. bad

    c. average

    d. good

    e. very good

15- Do you consider having a weight problem? (Please highlight answer.)

    a. Yes

    b. No

16- weight:___________ (lbs or kg) height: ____________ (feet or meters)

    17- Are you careful about your nutrition? (Please highlight answer.)

    a. Not at all

    b. A little

    c. Average

    d. A lot

    e. Very high

    18- In general, how would you evaluate your self esteem? (Please highlight answer.)

    a. Very low

    b. Low

    c. Average

    d. High

    e. Very high

    19- How many hours per week do you exercise? (Please highlight answer.)

    __________ per week

    20- How many cigarettes do you smoke per day on average? (Please highlight

    answer.)

    __________ per day

    21- How many glasses of alcohol do you drink per week on average? (Please

    highlight answer.)

    __________ per week

22- How many times per week do you use soft drugs (marijuana, hash… etc.)?

    (Please highlight answer.)

    __________ per week

    23- How many times per week do you use pharmaceutical drugs (not for medical

    reason)? (Please highlight answer.)

    __________ per week

    24- How many times per week do you use harder drugs (ecstasy, speed, etc…)?

    (Please highlight answer.)

    __________ per week

    25- How many hours do you spend on Internet on average per day?

    __________ per day

    26- Do you receive financial help from your family? (Please highlight answer.)

    a. Yes

    b. No

    27- Do you receive financial help from other individuals? (Please highlight answer.)

    a) Yes

    b) No

    28- - If yes, how much money do you have in hand per week on average?

    __________ dollars per week

29- What are you parents’ positions?

    Father: ____________________________

    Mother:____________________________

    30- Please highlight the range of salary that most corresponds to your parents

    financial situation (gross revenue, in US dollars).

    1. Less than 12 000

    2. 12 000 to 25 000

    3. 25 001 to 40 000

    4. 40 0001 to 60 000

    5. 60 001 to 80 000

    6. 80 001 to 100 000

    7. 100 001 to 120 000

    8. 120 001 and more

    31- Please highlight the range of salary that best represents your financial situation

    (gross revenue, in US dollars.):

    1. less than 12 000

    2. 12 000 to 25 000

    3. 25 001 to 40 000

    4. 40 001 to 60 000

    32- Within the last 6 months, how many times did you see a doctor concerning your

    health? (Please highlight answer.)

     1. never

     2. once

     3. 2-3 times

     4. 4-6 times

     5. 7 times and more

    33- If you answered once or more, please specify the location where you received

    medical advice (please highlight answer.) :

     1. public clinic

     2. private clinic

     3. hospital

     4. emergency

     5. health services at school or university

     6. other: please specify: ____________

    34- Who has taken the initiative concerning your medical consultation? (Please

    highlight answer.)

     1. myself

     2. one of my parents

     3. sister or brother

     4. friend

     5. boyfriend or girlfriend

     6, other, please specify: ____________

    THANK YOU!

    Please send back to interviewer.

Report this document

For any questions or suggestions please email
cust-service@docsford.com