CSI OIRA


CSI Health & Wellness Needs Assessment Survey

Purpose of Survey:  Please complete this survey so we can determine how to improve health and wellness programs and services to meet your needs.  Thank you.

Confidentiality:  Your responses will be used collectively for research purposes only and will be kept anonymous.

Participation:  Participation is voluntary.  You may choose not to participate or not to answer any specific question.  You may skip any question you are not comfortable answering.

Procedure:  Please complete the survey and click the "Submit" button when finished.

For more information:  Call Wellness at x3129 or the Health Center at x3045 (1C-112) if you have any questions or concerns.

1. How old are you?





 2. What sex/gender are you?




 3. How would you describe yourself?








 4. What is your current relationship status?





 5. Which term best describes you?





 6. How many total hours per week do you work and/or volunteer?




 7. Are you intending to be a full-time (12 or more credits) student?



 8. What class level are you?





 9. Do you consider your health to be:




 10. When was your last physical examination?




 11. How would you describe your weight?





 12. Are you trying to:





 13. Do you have severe allergies to:






 14. Have you ever been in an abusive relationship?





 15. Within the last 30 days have you used: (check all that apply)







 16. Over the last 30 days, how many times have you had five or more alcoholic drinks at a sitting?
    Yes No
17. Do you wear a seatbelt while riding in a car?  
18. Do you use sun screen or protective clothing while in the sun for 15 minutes or more?  
19. Do you eat at least 5 servings of fruits and vegetables daily?  
20. Do you exercise at least 3 times a week?  
21. Do you get enough sleep that you usually feel rested when you wake up?  
22. Is feeling sleepy during the day time a problem for you?  
23. Do you take vitamins?  
24. Do you drink more than 5 caffeinated beverages per day?  
25. Do you have health insurance?  
26. Do you have dental insurance?  
27. Do you have any dependent children?  
28. Do you feel happy about your life?  
29. Do you feel lonely?  
30. Do you feel very stressed more often than not?  
31. Do you feel socially confident?  
32. Have you ever been diagnosed with depression?  
33. Are you currently in therapy for depression?  
34. Are you currently taking medication for depression?  
35. Have you ever seriously considered attempting suicide?  
36. Have you experienced anxiety (panic) attacks?  
37. Do you have or have you been treated for an eating disorder?  
38. Within the last year, have you been sexually harassed?  
39. Within the last year, have you been a victim of stalking?  
40. Do you use tobacco products?  
41. If yes, are you considering quitting?


    Yes No
42. Have you ever abused over-the-counter drugs?  
43. Have you ever abused prescription drugs?  
44. Do you consume alcohol regularly?  
    Yes No N/A
45. Do you ever drive after drinking alcohol?  
46. Does your time spent on the internet interfere with responsibilities?  
47. If you gamble, does it interfere with responsibilities?  
    Yes No
48. Within the last year, have you been in a physical fight?  
49. Within the last year, have you been physically assaulted?  
50. Do you have hepatitis B or C?  
51. Are you sexually active?  
52. If yes, do you use condoms?
    Yes No
53. Have you or your partner had an unplanned pregnancy?  
54. Have you ever been tested for a sexually transmitted disease/infection?  
    Yes No Not Sure
55. Do you have a sexually transmitted disease/infection?  
56. Would you like to be tested for a sexually transmitted disease/infection?  
57. Would you like to be tested for HIV/AIDS?  
    Yes No
58. Do you have problems with your vision?  
59. Within the last year, have you had your eyes checked?  
60. Do you have hearing problems?  
61. Do you have high blood pressure?
    Yes No
62. Do you have a heart problem?  
63. Do you get chest pain with physical activity?  
64. Do you have asthma?  
65. Do you have diabetes?  
66. Do you have a family history of diabetes?  
67. Do you have a thyroid disorder?  
68. Do you have high cholesterol?
    Yes No
69. Have you had any urinary tract infections?  
70. Do you have anemia?  
71. Do you have a disability?  
72. Do you have a seizure disorder?  
73. Do you ever experience light-headedness or fainting?  
74. Do you have tuberculosis or have you received treatment to prevent it?  
75. Do you have cancer, cysts or tumors?  
76. Do you have intestine or stomach problems?  
    Yes No N/A
77. Females (40 and over): Have you had a mammogram in the last year?  
78. Females: Have you had a pap smear in the last year?  
79. Females: Do you do monthly self breast exams?  
80. Females: Do you have a history of breast cancer in your family?  
81. Females: Have you had the HPV vaccine?  
82. Males: Do you do monthly self testicular exams?  

Please click the 'Submit' button to finish.  Thank you for your assistance!