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  1. Surveys
  2. 2015
  3. September
  4. S
  5. Seasonal Pattern Assessment Questionnaire
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Questions marked with an * are required Exit Survey
 
 
* 1. Age -
 
< 18
 
18 - 29
 
30 - 44
 
45 - 59
 
60+
 
 
* 2. Place of birth - City / Province (State) / Country
   
 
 
* 3. Date form completed -
MonthDayYear
  
 
 
* 4. Sex -
 
 
5. How many years have you lived in this climatic area?
   
 
 
The purpose of this form is to find out how your mood and behaviour change over time. Please select the relevant options. Note: We are interested in your experience; not others you may have observed.
 
6. To what degree do the following change with seasons?
No change Slight change Moderate change Marked change Extremely marked change
* A. Sleep length
* B. Social activity
* C. Mood (overall feeling of well being)
* D. Weight
* E. Appetite
* F. Energy level
 
7. In the following questions, select the options for all applicable months. This may be a single month â˜‘ , a cluster of months, e.g. ☑ â˜‘ â˜‘, or any other grouping.
At what time of the year do you.....
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
* A. Feel best
* B. Gain most weight
* C. Socialize most
* D. Sleep least
* E. Eat most
* F. Lose most weight
* G. Socialize least
* H. Feel worst
* I. Eat least
* J. Sleep most
 
 
* 8. If you experience changes with the seasons, do you feel that these are a problem for you?
 
No
 
Yes
 
 
9. If your answer to the above question is YES then, using a scale of 1 - 5 (1 being the lowest and 5 being the highest) describe how this impacts your day to day life and overall wellbeing in the space provided below:
   
 
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