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How old are you?
 
15
 
16
 
17
 
18
 
19
 
Younger than 15
 
Older than 19
 
 
 
Gender
 
Male
 
Female
 
Gender Neutral
 
Other
 
 
 
Compared to other students, would you say your health is:
 
Poor
 
Fair
 
Good
 
Excellent
 
 
 
Do you have anything health wise that may prevent you from sleeping? (For example insomnia)
 
Yes
 
No
 
If yes, please specify:
 
 
 
What is your grade point average?
 
0.0-1.0
 
1.0-2.0
 
2.0-3.0
 
3.0-3.9
 
4.0
 
Please specify
 
 
 
 
What time do you go to bed Sunday-Thursday?
 
Too early
 
Kind of early
 
Right on time
 
Kind of late
 
Too late
 
Specify (PLEASE GIVE SPECIFIC TIME, NOT A RANGE):
 
 
 
What time do you wake up Monday-Friday?
 
Before 5:00 AM
 
Between 5:00 and 5:30
 
Between 5:30 and 6:00
 
Between 6:00 and 6:30
 
Later than 6:30
 
Please specify
 
 
 
During the last month, how many times have you stayed home because you were tired?
 
1 time
 
2 times
 
3 times
 
more than 3 times
 
If more than 3 times, how many times?
 
 
 
How do you feel when you are on your way to school?
Extremely unhappy
Unhappy
Neutral
Happy
Extremely happy
 
 
 
Why do you feel that way?
 
Too tired
 
I got just enough sleep
 
Other
 
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