Home  >  Appointments
sample photo

For more information:

Potter Building
6 Butterfield Road
Kingston, RI 02881

401-874-2246

health@etal.uri.edu

URI Health Services

2008 Behavior Survey

In our continued efforts to serve your needs and provide quality health services, we ask that your complete the following questionnaire. We would like to thank you in advance for your cooperation.


1. How old are you?
 Less than 17 years old
18 or 19 years old
20 to 22 years old
23 years old or older

2. What is your gender?
 Male
Female

3. What is your class standing?
 Freshman
Sophomore
Junior
Senior
Grad Student
Entering Freshman
Other

4. Are you a full-time student?
 Yes
No

5. How would you describe yourself?
 White - not Hispanic
Black - not Hispanic
Hispanic or Latino
Asian or Pacific Islander
American Indian or Alaskan Native
Other

6. Where will you be living this semester?
 College dormitory or residence hall
Fraternity or sorority house
Other university/college housing
Off-campus house or apartment
Parent/guardian's home
Other

7. How many hours a week do you plan to work?
 0 hours
1-9 hours
10-19 hours
20-29 hours
30-39 hours
40 hours
More than 40 hours

8. How often do you wear a seat belt?
 Never wear a seat belt
Rarely wear a seat belt
Sometimes wear a seat belt
Most of the time wear a seat belt
Always wear a seat belt

9. When you rode a bicycle during the past 12 months, how often did you wear a helmet?
 I did not ride a bicycle during the past 12 months
Never wore a helmet
Rarely wore a helmet
Sometimes wore a helmet
Most of the time wore a helmet
Always wore a helmet

10. When you participated in water sports during the past 12 months, how often did you drink alcohol?
 I did not participate in water sports during the past 12 months
Never drank alcohol
Rarely drank alcohol
Sometimes drank alcohol
Most of the time drank alcohol
Always drank alcohol

11. During the past 30 days, how many times did you ride in a car or other vehicle when you had been drinking alcohol?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

12. During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

13. During the past 12 months, on how many days did you carry a weapon such as a gun, knife or club? Do not count carrying a weapon as part or your job.
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

14. During the past 12 months, how many times were you in a physical fight?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or 7 times
8 or 9 times
10 or 11 times
12 or more times

15. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

16. During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse and alcohol was involved?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

17. How many times in the past 3 months have you felt moderately or severely angry?
 0 times
1 time
2 or 3 times
4 or 5 times
6 to 10 times
11 or more times

18. How many times in the past 12 months have you felt moderately or severely depressed?
 0 times
1 time
2 or 3 times
4 or 5 times
6 to 10 times
11 or more times

19. During the past 12 months, did you ever seriously consider suicide?
 Yes
No

20. During the past 12 months, did you make a plan about how you would attempt suicide?
 Yes
No

21. During the past 12 months, how many times did you actually attempt suicide?
 0 times
1 time
2 or 3 times
4 or 5 times
6 or more times

22. During the past 30 days, on the days you smoked how many cigarettes did you smoke per day?
 I did not smoke cigarettes during the past 30 days
Less than 1 cigarette per day
1 cigarette per day
2 to 5 cigarettes per day
6 to 10 cigarettes per day
11 to 20 cigarettes per day
More than 20 cigarettes per day

23. How old were you when you first started smoking cigarettes regularly?
 I have never smoke cigarettes regularly
12 years or younger
13 or 14 years old
15 or 16 years old
17 or 18 years old
19 or 20 years old
21 to 24 years old
25 years old or older

24. How many times have you tried to quit smoking?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

25. During the past 30 days, on how many days did you use chewing tobacco or snuff?
 0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

26. How old were you when you had your first drink of alcohol other than a few sips?
 12 years or younger
13 or 14 years old
15 or 16 years old
17 or 18 years old
19 or 20 years old
21 to 24 years old
25 years old or older
I have not tried alcohol

27. During the past 30 days, on how many days did you have at least one drink of alcohol?
 0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

28. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?
 0 days
1 day
2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 or more days

29. During the past 30 days, how many drinks containing alcohol did you have on the days in which you drank?
 I didn't drink in the last 30 days
1-2 drinks
3-4 drinks
5-6 drinks
7-10 drinks
11 or more drinks

30. During the last 30 days, what is the highest number of drinks that you drank on any one occasion?
 I didn't drink in the last 30 days
1-2 drinks
3-4 drinks
5-6 drinks
7-10 drinks
11 or more drinks

31. Did you drink until you felt drunk or intoxicated at least once in the last month?
 Yes, and I do not intend to stop getting drunk
Yes, but I intend to stop getting drunk in the next six months
Yes, but I intend to stop getting drunk in the next 30 days
No, I have not been drunk in the last month, but I have been drunk in the last six months
No, I have not been drunk in the last six months

32. How old were you when you tried marijuana for the first time?
 I've never tried marijuana
12 years or younger
13 or 14 years old
15 or 16 years old
17 or 18 years old
19 or 20 years old
21 to 24 years old
25 years old or older

33. During the past 30 days, how many times did you use marijuana?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 or more times

34. During your life, how many times have you used any form of cocaine including powder, crack, or freebase?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

35. During your life, how many times have you sniffed glue, or breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

36. During your life, how many times have you taken steroids for body building purposes?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

37. During your life, how many times have you used prescription medication such as pain killers, anti-anxiety medication, sleeping pills, appetite suppressants, etc. without a doctor\s prescription?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

38. During your life, how many times have you used any other type of recreational drug, such as LSD, PCP, ecstasy, mushrooms, speed, ice, or heroin?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

39. During the past 30 days, how many times have you used any recreational drug in combination with drinking alcohol?
 0 times
1 or 2 times
3 to 9 times
10 to 19 times
20 to 39 times
40 to 99 times
100 or more times

40. During your life, how many times have you used a needle to inject any recreational drugs into your body?
 0 times
1 time
2 or more times

41. How old were you when you had sexual intercourse for the first time?
 I have not had sexual intercourse
12 years or younger
13 or 14 years old
15 or 16 years old
17 or 18 years old
19 or 20 years old
21 to 24 years old
25 years old or older

42. During the past 3 months, how many partners did you have sexual intercourse with?
 I have never had sexual intercourse
none
1 partner
2 partners
3 partners
4 partners
5 partners
6 or more partners

43. During the past 3 months, how many times did you have sexual intercourse?
 0 times
1 time
2 or 3 times
4 to 9 times
10 to 19 times
20 or more times

44. During the past 3 months, how often did you or your partner use a condom, oral contraceptives, or other birth control method?
 I have not had sexual intercourse during the past 3 months
Never used a condom, contraceptive, or other birth control
Rarely used a condom, contraceptive, or other birth control
Sometimes used a condom, contraceptive, or other birth control
Most of the time used a condom, contraceptive, or other birth control
Always used a condom, contraceptive, or other birth control

45. The last time you had sexual intercourse, did you or your partner use a condom?
 not having sexual intercourse
Yes
No

46. In the last 3 months did you drink alcohol or use drugs before you had sexual intercourse?
 not having sexual intercourse
Yes
No

47. The last time you had sexual intercourse, what method did you or your partner use to prevent pregnancy?
 not having sexual intercourse
No method was used to prevent pregnancy
Birth control pills
Condoms
Withdrawal
Some other method

48. How many times have you been pregnant or got someone pregnant?
 0 times
1 time
2 or more times
not sure

49. During your life, have you ever been forced to have sexual intercourse against your will?
 Yes
No

50. Have you ever had your blood tested for HIV/AIDS?
 Yes
No

51. Do you feel you have had sufficient education regarding sexually transmitted diseases?
 Yes
No

52. Are you practicing safer sex as the result of sexually transmitted disease education?
 not having sexual relations
always
often
sometimes
seldom
never

53. Have you ever had a sexually transmitted disease?
 Yes
No

54. My level of self-esteem is?
 below what I'd like it to be
about what I'd like it to be
above what I'd like it to be

55. How do you describe your body?
 Very underweight
Slightly underweight
About the right weight
Slightly overweight
Very overweight

56. Which of the following are you trying to do about your body?
 Lose weight
Gain weight
Stay the same weight
I am not trying to do anything about my weight

57. Have you ever dieted or exercised to lose weight or to keep from gaining weight?
 Yes
No

58. Have you ever vomited or taken laxatives to lose weight or keep from gaining weight?
 Yes
No

59. Have you ever taken diet pills to lose weight or keep from gaining weight?
 Yes
No

60. Do you feel you have an eating problem or disorder of some kind?
 not at all
in the past but not presently
presently but not in the past
both presently and in the past

61. Yesterday, how many times did you eat a piece of fruit or drink fruit juice?
 0 times
1 time
2 times
3 or more times

62. Yesterday, how many times did you eat green salad or vegetables?
 0 times
1 time
2 times
3 or more times

63. Yesterday, how many times did you drink milk, eat cheese, yogurt, or other dairy products?
 0 times
1 time
2 times
3 or more times

64. Do you eat a vegetarian diet?
 never
seldom
sometimes
often
always

65. On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?
 0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

66. On how many of the past 7 days did you do exercise or participate in sport activities for at least 20 minutes?
 0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

67. During the past year, in how many sports teams (intramural or extramural) did you participate?
 0 teams
1 teams
2 teams
3 or more teams

68. When making behavioral choices, who and/or what has the greatest influence on your decision-making?
 friends/peers
relatives
parents
TV/media
siblings
Other

69. On which of the following health topics would you like Health Services to provide more information.
 Tobacco use
Alcohol and other drug use
Abusive relationships
Injury and safety
Suicide
Birth control/pregnancy
Sexually transmitted infections(STI)
HIV/AIDS
Nutrition
Physical activity and fitness
Body image
Eating issues and disorders
Self-esteem
Dealing with stress
Anger management
Relationships
Family issues
Abstinence
Other

70. I am satisfied with my life in the past.
 Strongly Disagree
Disagree
Agree
Strongly Agree

71. I am satisfied with my current life.
 Strongly Disagree
Disagree
Agree
Strongly Agree

72. I will be satisfied with my life in the future.
 Strongly Disagree
Disagree
Agree
Strongly Agree

73. Life does not have much meaning.
 Strongly Disagree
Disagree
Agree
Strongly Agree

74. I do not enjoy much about life.
 Strongly Disagree
Disagree
Agree
Strongly Agree

75. I feel unsettled about the future.
 Strongly Disagree
Disagree
Agree
Strongly Agree

76. I am unable to cope with difficult situations.
 Strongly Disagree
Disagree
Agree
Strongly Agree

77. I successfully solve problems that come up.
 Strongly Disagree
Disagree
Agree
Strongly Agree

78. I feel able to cope with stress.
 Strongly Disagree
Disagree
Agree
Strongly Agree

79. I feel pressured by others.
 Strongly Disagree
Disagree
Agree
Strongly Agree

80. I feel overwhelmed.
 Strongly Disagree
Disagree
Agree
Strongly Agree

81. I feel I have more stress than usual.
 Strongly Disagree
Disagree
Agree
Strongly Agree

82. My social support system from my FRIENDS is...
 non-existent
poor
fair
good
very good
excellent

83. My social support system from my FAMILY is...
 non-existent
poor
fair
good
very good
excellent

84. My current feelings about my own self worth are...
 non-existent
poor
fair
good
very good
excellent

85. The following members of my family abused alcohol or drugs before I was 18 years old.
 mother
father
brothers and/or sisters, including step/half
grandparent(s)
stepparent or guardian

86. How satisfied are you with your "mental/psychological" self?
 unsatisfied
not very satisfied
satisfied
mostly satisfied
very satisfied

87. How satisfied are you with your "physical/physiological" self?
 unsatisfied
not very satisfied
satisfied
mostly satisfied
very satisfied