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 |
___________________ |
_____________ |
