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Surveys
2014
December
M
MRC
MRC
0%
Exit Survey
Which of the following best represents your racial or ethnic heritage? Choose all that apply.
Non-Hispanic White or Euro-American
Black, Afro-Caribbean, or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern
Pacific Islander or Hawaiian
Native American or Alaskan Native
Other
Select one that describes the economic class you were raised in best.
Poverty
Low Income
Middle Class
Upper Middle Class
Upper Class
$$$
How old are you?
14-18
18-25
25-30
30-35
35-40
40-45
45-50
50-55
55-60
60-65
65-70
70+
Select all of which pertain to your chosen religion / spirituality.
Christianity
Mormonism
Islam
Judaism
Buddhism
Hinduism
Taoism
Amish
The Occult
Christian Science
Jehovah's Witness
Lutheranism
Rastafari
Satanism
Scientology
Seventh-day Adventist
Shamanism
Wicca
A little bit of everything
Other
Chose one or more that best describe your sexuality.
Heterosexual
Homosexual
Pansexual
Bisexual
Asexual
Polysexual
Polyamory
Other
Have you had an abortion?
No.
No, and I would never.
Yes.
Yes, and more than one.
Yes, as the partner involved.
Do you have any mental/emotional issues or illnesses (select all that apply).
No mental illnesses to my knowledge.
ADD
ADHD
Addiction to drugs
Addiction to alcohol
Bi-Polar
Boarderline
Bulimia
Anti-social
Anorexia Nervosa
Autism
Aspbergers
Body Dysmorphia Disorder
Catatonia Schizophrenia
Depressive Disorder
Down Syndrome
Dyslexia
Fugue State
Huntington's
Hypochondria
Insomnia
Impulse Control
Mood Disorder
Narcissistic Personality
Nightmare Disorder
Pain Disorder
Panic Disorder
Paranoid Personality Disorder
Any phobic disorder
PTSD
Psychotic Disorder
Schizophrenia
SAD
Sleep terror / Sleep walking
Tourettes Syndrome
Trichotillomania
Other
Have you ever been married?
Yes
No
Yes, and divorced
Have you been sexually assaulted?
Yes
No
Have you experienced abuse? Select all that apply. LOVE YOU BBs <3
Physical
Emotional
Sexual
Other
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