I am doing undergraduate research in individuals with mood disorders. Your responses are 100% confidential and your IP addresses cannot be traced. Please answer each question to the best of your ability to help with the accuracy of my research. Thank you for your time.
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Answer each question to the best of your ability. You can skip a question if you do not feel comfortable giving the answer.
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1. Please specify your gender. Male Female Other, please specify
2. What is your age?
3. What is your sexual orientation? Heterosexual Gay/Lesbian Bisexual Unsure/Other
4. What is the highest level of education that you have completed? Grade School High School/GED Some College Bachelor's Degree Graduate Student Master's Degree Doctorate Degree
5. What is your religious preference? Catholic Protestant Latter-Day Saint Jewish Muslim Hindu Buddhist None Other, please specify
6. What is your employment status? Full Time Part Time Not employed
7. What is your occupation? Student Homemaker Retired Government/Military Health Care Education Public Service Mental Health Business/Retail Law Science Other, please specify
8. What is your current annual income? Less than $10,000 $10,000-$19,999 $20,000-$29,999 $30,000-$39,999 $40,000-$49,999 $50,000-$59,999 $60,000-$69,999 $70,000 or above
9. What is your race or ethnic origin? American Indian / Alaska Native Asian / Pacific Islander African-American / Black Caucasian / White Mexican-American / Hispanic European Decent India / Middle-Eastern South American Decent Latin Origin Biracial Other, please specify
10. What is your current relationship status? Single/Never Married, Not Dating Singe, Divorced/Separated Single, Widowed Dating Committed relationship Living Together Engaged to be married Civil Union Married, first marriage Married, 2nd/3rd Marriage Other, please specify
11. On the following checklist, please indicate problems that are a concern to you about yourself. chronic illness/pain depression anxiety/worries stress sexual abuse/rape eating disorder relationship problem physical problem excessive alcohol/drugs family relationships sexual problems parenting self-esteem lack of assertiveness suicidal thoughts anger grief self-injury/self-harm sexual addiction emotional abuse in childhood physical abuse in childhood sexual abuse in childhood Other, please specify
12. Please list all medications you are taking, including herbal medications:
13. Medication 2
14. Medication 3
15. Medication 4
16. Medication 5
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