Egzamin 2
BIOGRAPHICAL INVENTORY:
1. Age *
Your answer
1.2. Gender *
1.3. Year of study *
1.4. Program: *
1.5. Are you? *
1.5.1 if yes; how long?
Your answer
1.6 Do you have children? *
1.6.1 if yes; how many?
Your answer
1.7. Your general medical conditions: *
1.8 How are you doing with your study? *
1.8.1 Are you study in the night? *
1.8.2 In which hours?
Your answer
1.9. Do you often go to sleep late because of social activities? *
1.10 Do you smoke cigarettes? *
1.10.1 If yes, how many
Your answer
1.10.2 If yes, For how many years ?
Your answer
1.11. Do you drink alcohol? *
1.11.1 If yes, What kind?
1.11.2 If yes, How many years have you been drinking?
Your answer
1.12. Have you ever been drunk? *
1.12.1 If yes how many times?
Your answer
1.13. Do you drink coffee? *
1.13.1 How many cups per day?
Your answer
1.14. Do you take any stimulants (Aderal, cocaine, amphetamine)? *
1.14.1 if Yes, Which substance?
Your answer
1.15 Do you admit to using marihuana? *
1.15.1 If yes, In which amount?
Your answer
1.15.2 If yes, For how long?
Your answer
1.16 Do you take any sleeping pills? *
1.17 Do you watch TV? *
1.17.1 If yes, How many hours a day?
Your answer
1.18. How many hours a day do you spend on the internet? *
Your answer
1.19. Do you spend more time on the internet than you have planned? *
1.20 Had ever your family member (who) experienced: *
Required
1.21 Have you had any suicides in the family? *
1.22 Did your parents supervised regularity and duration of your sleep in childhood?
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