Check the following items which apply to you:

Sex: _____ Male Age: _____

_____ Female

Race: _____ Malay _____ Chinese

_____ Indian

_____Other _____ On Campus

Living arrangements: _____ Off Campus without parents _____ Off campus with parents

Transportation 1. Do you have any mode of transportation? Yes or No 2. If yes, what is it? Car, motorcycle, bicycle or other:_______________ 3. If no, do your friends have any mode of transportation?

Health Problems On the line beside each health problem write in how many times you have experienced it OVER THE PAST MONTH. (Note: If you experience it just about every day this would be about 28, about twice a week would be equal to 8, one a week 4, once a month 1, not at all leave blank.)

_____ headache

_____ ear infection

_____ eye infection

_____ sinus infection

_____ nose bleeds

_____ bronchitis or laryngitis

_____ pneumonia

_____ cough

_____ a "cold" or the flu

_____ sore-throat

_____ "mono"

_____ acne flair-up

_____ hay fever/asthma flair-up

_____ bleeding gums

_____ tooth abscess

_____ stomach upset

_____ nausea or vomiting

_____ ulcer

_____ diarrhea

_____ high blood pressure

_____ muscle strain

_____ a sprain

_____ a broken bone

_____ cut or hurt myself so that I needed to see a doctor

_____ lack of energy

Other health problem (write in)

______________________________________________

Women only:

_____ menstrual irregularity

_____ menstrual cramps

_____ vaginal yeast infection

_____ other kind of vaginal infection

_____ bladder/urinary tract infection

_____ sexually transmitted disease

Write in which ones.

_________________________________________________

Men only:

_____ burning on urination

_____ urinary tract infection

_____ sexually transmitted disease

Write in which ones.

_________________________________________________

Health related problems over the past month for all students

1. Over the past month how many times have you visited a doctor or the student health service because you were sick? __________

2. How many times have you missed class or other commitment because you were sick during the past month? __________

3. How many courses of antibiotics have you taken during the past month? _______ Lifestyle habits over the past month Exercise 1. How many times did you exercise during the past month? __________

2. When you exercised, on the average how many minutes did you engage in the exercise? __________ 3. In one week time period, how many times do you exercise and how long on average? _____________(approximately will do too) 4. What kind of exercise you doing and is it the same one for most of the time? _______________ 5. Do you practice yoga before? Yes or No

Emotion and Feeling 1. How many times did you feel "stressed out" (under stress) during the past month? __________ 2. Is it due to examination getting nearer or financial problem or other problem? Please state if it is other problem. ___________________ 3. When you felt stressed out how many hours did it usually last? __________ 4. What do you do when you feel stress? Do you just leave it alone? ___________________ 5. How many times did you feel angry or irritated during the past month? _________ 6. When you felt angry or irritated how many hours did it usually last? __________ 7. Over the past month how many times did you feel depressed? __________ 8. When you felt depressed how many hours did it last? __________

Habits and behaviors 1. During the past month how many times did you drink beer? Please circle. a. every day b. two or three times a week c. once a week d. at least once a month but less than once a week e. not at all

2. When you drank beer how many average size glasses or cans did you usually consume at any one sitting? __________ 3. During the past month circle how many times you drank wine or a wine cooler. a. every day b. two or three times a week c. once a week d. at least one a month but less than once a week e. not at all 4. When you drank wine how many average size glasses or small bottles of wine coolers did you usually consume at any one sitting? __________ 5. During the past month how many times did you drink a hard liquor (vodka, rum, whiskey, etc.)? Please circle. a. every day b. two or three times a week c. once a week d. at least once a month but less than once a week e. not at all 5. When you drank liquor how many shot glasses or shots in mixed drinks did you usually consume at any one sitting? __________ 6. During the past month how many days did you use tobacco? __________ 7. How many cigarettes did you smoke on the days you smoked? __________ 8. How many dips of chewing tobacco/snuff did you use on days you used it? __________ 9. How many days did you smoke marijuana during the past month? __________ 10. How many joints did you smoke on the days you used marijuana? __________ 11. How many days did you binge out on food? __________ 12. On the days you binged out on food how many times did you purge (vomit or use laxative)? __________ 13. Do you have proper time management and do you follow it? ________________ Meals 1-Strongly disagree 2-disagree 3-slightly disagree 4-slightly agree 5-agree 6-strongly agree

1. Do you usually eat outside or inside? 2. Do you normally cook at the hostel? 3. Do you eat vegetables for each meal? 4. Do you have fish daily? 5. Do you eat meat for each meal? 6. Do you take fruits daily?

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