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Emotion and Personality Survey
1.
General Information
How did you hear about this study?
Listserve (Please specify below)
Link from another website (Please specify below)
Craigslist city (Please specify below)
Web search
From a friend
Other (Please specify below)
Please specify
What is your age?
Gender:
Male
Female
What ethnic/racial/cultural, and/or national background do you most identify with?
European American
African American
Asian American
Latin American
Middle Eastern American
Indian (from India) American
Native American
Pacific Islander American
Other (please specify)
In what country did you spend most of your youth?
In what city and state did you spend most of your youth?
What is the zip code/postal code of the place where you spent most of your youth?
How long did you live there? (In years)
In what country are you currently living?
In what city and state do you currently live?
What is the zip/postal code of the place where you currently live?
How long have you lived there? (In years)
Where would you place your parents on the following spectrum for social class?
Lower class
Working class
Middle class
Upper class
If financially independent, where would you place yourself on the following spectrum for social class? (if you are not financially independent, please select the 'Not financially independent' option)
Lower class
Working class
Middle class
Upper class
Not financially independent
Number of years of formal education your mother or father (whichever is the highest) has completed:
8th grade or below
Some high school
High school graduate
Some college or university
A.A./A.SB.A./B.S
Some graduate school
M.A./M.S
Ph.D
J.D
M.D
Number of years of formal education you have completed:
8th grade or below
Some high school
High school graduate
Some college or university
A.A./A.SB.A./B.S
Some graduate school
M.A./M.S
Ph.D
J.D
M.D
Are you active in sports?
Yes
No
If yes, which sports?
How much time do you spend participating in sport-related activities?
Less than 1 hour per week
1-4 hours a week
5-10 hours a week
11-15 hours a week
More than 15 hours a week
At what level do you participate in sports activity?
Intercollegiate
Intramural
Individual
Other (please specify)
What is or was your religious background i.e. what religion did you grow up with?
Evangelical Protestant Church
Mainline Protestant Church
Historical Black Churches
Catholic
Orthodox
Other Christian
Mormon
Jehovah's Witness
Jewish
Muslim
Hindu
Buddhism
Jewish
Muslim
Hindu
Buddhist
Mormon
None
Other (please specify)
Sexual Orientation:
Heterosexual
Homosexual
Bisexual
What is your current relationship status? (please check the one that applies best to you)
Married/living with an intimate other
Separated/divorced
Never married
Widowed
Have you ever had a problem with drugs/alcohol?
Yes
No
If yes, what was your drug of choice?
If you have or had a problem with drugs/alcohol, please indicate:
used to have a problem, but stopped using over a year ago
used to have a problem, but stopped using a year ago
used to have a problem, but stopped using 6-11 months ago
used to have a problem, but stopped using 3-6 months ago
used to have a problem, but stopped using 1-3 months ago
used to have a problem, but stopped using within last 30 days
currently using
Do you have any psychiatric or mental health condition(s)? (e.g., depression, anxiety, panic attacks, etc.)
Yes
No
If yes, what psychiatric or mental health condition(s) do you have?
Condition 1
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
Condition 2
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
Condition 3
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
If there are any other condition(s), please list here
Do you take any medication for psychiatric or mental health condition(s)?
Yes
No
What medication(s) do you take, and for what condition(s)?
Condition
Medication
First
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
-- Select an option --
Adderall</Cytomel
Depakote
Dexadrine
Effexor (venlafaxine)
Elavil
Geodon (ziprasidone)
Inderal (propranolol)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro
lithium
Luvox (fluvoxamine)
Mirapex<
Neurontin (gabapentin)
Nortriptyline
Oxycontin (oxycodone)
Paxil (paroxetine)
Propranolol
Prozac (fluoxetine)
Ritalin</option>
Sertraline (Zoloft)
SonataStrattera
Tegretol (carbamazepine)
Topamax (topirimate)
Trileptal (oxcarbazepine)
Trazodone
Valium (diazepam)
Wellbutrin (bupropion)
Xanax (alprazolam)
Zoloft (sertraline)
Zyprexa (olanzapine)
Second
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
-- Select an option --
Adderall</Cytomel
Depakote
Dexadrine
Effexor (venlafaxine)
Elavil
Geodon (ziprasidone)
Inderal (propranolol)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro
lithium
Luvox (fluvoxamine)
Mirapex<
Neurontin (gabapentin)
Nortriptyline
Oxycontin (oxycodone)
Paxil (paroxetine)
Propranolol
Prozac (fluoxetine)
Ritalin</option>
Sertraline (Zoloft)
SonataStrattera
Tegretol (carbamazepine)
Topamax (topirimate)
Trileptal (oxcarbazepine)
Trazodone
Valium (diazepam)
Wellbutrin (bupropion)
Xanax (alprazolam)
Zoloft (sertraline)
Zyprexa (olanzapine)
Third
-- Select an option --
ADHD
Substance Abuse Disorder
Adjustment Disorder
Asperger Syndrome
Autism
Irritability
OCD
OC Spectrum Disorder
Panic Attacks
Phobia(s)
PTSD
Public Speaking Anxiety
Social Phobia
Anxiety Disorder
Depression/Anxiety
Depression (Unipolar Mood Disorder
Bipolar I
Bipolar II
Bipolar Spectrum Disorder
Cyclothymia
Dysthymia
Borderline Personality Disorder
Impulse Disorder(s
Insomnia/Sleep Disorder
Psychotic Disorder NOS
Schizoaffective Disorder
Schizophrenia
Sexual Disorder(s)
-- Select an option --
Adderall</Cytomel
Depakote
Dexadrine
Effexor (venlafaxine)
Elavil
Geodon (ziprasidone)
Inderal (propranolol)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro
lithium
Luvox (fluvoxamine)
Mirapex<
Neurontin (gabapentin)
Nortriptyline
Oxycontin (oxycodone)
Paxil (paroxetine)
Propranolol
Prozac (fluoxetine)
Ritalin</option>
Sertraline (Zoloft)
SonataStrattera
Tegretol (carbamazepine)
Topamax (topirimate)
Trileptal (oxcarbazepine)
Trazodone
Valium (diazepam)
Wellbutrin (bupropion)
Xanax (alprazolam)
Zoloft (sertraline)
Zyprexa (olanzapine)
If you take any other medication(s) for psychiatric or mental health condition(s), please list here along with for what condition(s) you take the medication(s).