Sex: (Circle one)
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Male
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Female
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Occupation:
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Year in School:
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Type of work (if any):
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Last grade in Math Class (as appears on last report card):
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A+ A A- B+ B B- C+ C C- D+ D D- F
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Last grade in English Class (as appears on last report card):
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A+ A A- B+ B B- C+ C C- D+ D D- F
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Overall average grade (as appears on last report card):
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How often do you exercise in an average week? (Circle one)
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Every day
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4–6 days a week
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1–3 days a week
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Less than one day a week
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What is your family situation:
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Parents are married or live together
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Parents live apart
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Parents are divorced, I live with mom or dad
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Live with legal guardian
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Average total number of hours a day spent on Internet: (Circle one)
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Less than 1
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1–2
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3–4
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More than 4
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Average total number of hours a day spent on Computer games: (Circle one)
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Less than 1
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1–2
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3–4
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More than 4
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Average total number of hours a day spent on other console games such as Playstation, N64, etc. (Circle one)
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Less than 1
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1–2
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3–4
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More than 4
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Total number of hours a day spent watching television: (Circle one)
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Less than 1
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1–2
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3–4
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More than 4
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Type of games played : (Circle as many as apply)
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Sports
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Strategy
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Action
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Other
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Favorite game:
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How many detentions have you had in the past month?
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Have you been suspended from school in the past year?
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YES
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NO
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If yes, how many times?
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Have you been in a physical fight in the past year?
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YES
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NO
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If yes, how many times?
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Have you been arrested in the past year?
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YES
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NO
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If yes, how many times?
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Do you drink alcohol? (Circle one)
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YES
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NO
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If yes, how many drinks per week on average?
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Do you smoke? (Circle one)
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YES
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NO
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If yes, how many cigarettes per day on average?
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Do you smoke marijuana? (Circle one)
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YES
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NO
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If yes, how many joints per week on average?
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Other drugs and amount:
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How often do you use alcohol/cigarettes/drugs while playing video games? (Circle one)
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ALWAYS
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SOMETIMES
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RARELY
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NEVER
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Rarely
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Occasionally
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Frequently
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Often
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Always
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Does Not Apply
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1. How often do you find that you play video games longer than you intended?
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2. How often do you neglect household chores to spend more time playing video games?
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3. How often do you prefer the excitement of playing video games to spending time with your girl/boy friend or family?
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4. How often do you play video games with friends?
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5. How often do others in your life complain to you about the amount of time you spend playing video games?
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6. How often do your grades or schoolwork suffer because of the amount of time you spend playing video games?
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7. How often do you play video games before something else that you need to do?
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8. How often does your job performance or productivity suffer because of playing video games?
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9. How often do you become defensive or secretive when anyone asks you how much time you spend playing video games?
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10. How often do you block out disturbing thoughts about your life with thoughts of playing video games?
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11. How often do you find yourself anticipating when you will play video games again?
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12. How often do you fear that life without video games would be boring, empty, and joyless?
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13. How often do you snap, yell, or act annoyed if someone bothers you while you are playing video games?
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14. How often do you lose sleep due to late-night video games?
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15. How often do you feel preoccupied with playing video games when not, or fantasize about doing so?
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16. How often do you find yourself saying "just a few more minutes" when playing video games?
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17. How often do you try to cut down the amount of time you spend playing video games and fail?
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18. How often do you try to hide how long you've been playing video games?
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19. How often do you choose to spend more time playing video games over going out with others?
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20. How often do you feel depressed, moody, or nervous when you are not playing video games, which goes away once you are back playing?
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Subjects were also asked to complete the Beck Depression Inventory.
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Production note: This article was amended post-publication. For copyright reasons, the Beck Depression Inventory was removed.
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