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Example Survey of Psychological Problems

This is an example of a survey to assess the prevalence of psychological problems in students’ lives. You will be very surprised to know how many people are touched by these issues.

If a close family member currently has or once had a particular psychological problem, check the space under “close family member.” Do the same under “close friend.” The problem could have been diagnosed as such by a professional or be one you feel the individual has or had. If more than one family member or friend has had the problem, you should indicate with as many check marks as individuals involved.

 

Psychological Problem Close Family Member  

 

Close Friend

 

 
1. Drinking problem (alcohol abuse or alcoholism) ___________________ _____________
 

2. Frequent periods of anxiety or seriously limiting fears

  

___________________

  

_____________
 

3. Stress-related physical disorder such as migraine or ulcer

  

___________________

  

_____________
4. Schizophrenia  

___________________

  

_____________
 

5. Dependency on illicit drug such as marijuana or cocaine

  

___________________

  

_____________
 

6. Alzheimer’s disease

  

___________________

  

_____________
 

7. Depression lasting at least two weeks

  

___________________

  

_____________
 

8. Eating disorders such as anorexia or bulimia

  

___________________

  

_____________
 

9. Intellectual disability

  

___________________

  

_____________

 

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