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Table 5 UNIVERSITY OF VERMONT STUDENT SURVEY (To be completed individually by student)

From: A cross-sectional analysis of video games and attention deficit hyperactivity disorder symptoms in adolescents

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