Page 1 of 4
Experiment 2:
Questionnaires
Please answer honestly. Your details will be kept strictly confidential, and the identifiable details will be erased upon completion of the study.
Name
*
Age
*
Phone Number
*
Email
*
Today's Date
*
Note: If you are filling the form using a mobile phone, please consider rotating the screen.
Have you suffered a serious head injury in the past?
*
Have you suffered a serious head injury in the past?
A
Yes
B
No
If yes, when?
Have you been diagnosed with any neurological disease?
*
Have you been diagnosed with any neurological disease?
A
Yes
B
No
If yes, which neurological disease?
Have you been diagnosed with any psychiatric/psychological disorder?
*
Have you been diagnosed with any psychiatric/psychological disorder?
A
Yes
B
No
If yes, which psychiatric/psychological disorder?
*
Post-Graduate or Professional Degree
Graduate Degree
Higher Secondary Certificate
Middle School Certificate
Literate, less than Middle School Certificate
Illiterate
Mother's Education
Father's Education
Instructions:
Read each of the following statements and indicate the extent to which these statements are true of your actual behavior.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Not Applicable
1. Despite being aware of the negative effects of excessive alcohol use, I often end up taking more drinks than I intend to.
2.
I cannot stop drinking even if I know that my loved ones are worried about it.
3.
Even when I have no money, I borrow it from others to get a drink.
Next