Section 1 of 1
Teen Dating on Development
Hi! My name is Amy, and I am conducting research for the Families in Canada
course. This questionnaire has been designed to determine the impacts teen dating on adolescent development.
Please be as honest as possible when answering the questions. Your results will remain
confidential and anonymous. By taking this survey you are consenting to your responses
being used in my research.
Thank you for your time and cooperation.
course. This questionnaire has been designed to determine the impacts teen dating on adolescent development.
Please be as honest as possible when answering the questions. Your results will remain
confidential and anonymous. By taking this survey you are consenting to your responses
being used in my research.
Thank you for your time and cooperation.
How old are you?
How old are you?
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Date
Time
13-15
16-19
20-30
31-40
41-50
50+
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or
add "Other"
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What Gender do you Identify with?
What Gender do you Identify with?
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Male
Female
Non Binary
Prefer not to say
Other:
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Are you religious? If so, what religion do you associate with?
Are you religious? If so, what religion do you associate with?
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How many siblings do you have?
How many siblings do you have?
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None
1
2
3
4+
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If you have siblings, do you think they have affected your view on dating?
If you have siblings, do you think they have affected your view on dating?
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Are your parents still together?
Are your parents still together?
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Married/dating
Divorced
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Do you think your parent's marital status affected your relationship choices?
Do you think your parent's marital status affected your relationship choices?
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How would you describe your relationships with your friends?
How would you describe your relationships with your friends?
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Extremely Poor
Extremely Positive
0
1
2
3
4
5
6
7
8
9
10
1
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5
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(0 points)
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Do you think your friendships impact your romantic relationships?
Do you think your friendships impact your romantic relationships?
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Do you think social media has impacted your views on what a healthy relationship is?
Do you think social media has impacted your views on what a healthy relationship is?
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Yes
No
Sort of
Don't know
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How many relationships were you in/have been in during your teen years?
How many relationships were you in/have been in during your teen years?
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What age did you start dating?
What age did you start dating?
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Are you currently in a relationship?
Are you currently in a relationship?
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Yes
No
It's complicated
Other:
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How would you describe your relationships (if you have been/were in any during adolescence)?
How would you describe your relationships (if you have been/were in any during adolescence)?
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Very poor
Very positive
0
1
2
3
4
5
6
7
8
9
10
1
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5
Label (optional)
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(0 points)
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How have relationships impacted your self esteem?
How have relationships impacted your self esteem?
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Hasn't impacted self esteem
Positively impacted
Negatively impacted
Other:
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How would you rate your self esteem?
How would you rate your self esteem?
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Extremely poor
Extremely positive
0
1
2
3
4
5
6
7
8
9
10
1
Label (optional)
5
Label (optional)
Answer key
(0 points)
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How do you handle conflicts in relationships?
How do you handle conflicts in relationships?
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Do you think your past relationships have impacted how you handle conflict now?
Do you think your past relationships have impacted how you handle conflict now?
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Has dating impacted your focus on school or extracurricular activities?
Has dating impacted your focus on school or extracurricular activities?
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Yes
No
Not sure/don't know
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Is there anything you’ve learned or experienced during relationships that you think will impact your future relationships/have impacted your current relationship?
Is there anything you’ve learned or experienced during relationships that you think will impact your future relationships/have impacted your current relationship?
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