Technology Usage Survey

Technology Usage Survey
Technology includes: TV, cell phones, tablets, desk top computers, laptop computers, video games, movies, cartoons, and music videos (not audio).
Technology Addiction: It includes all obsessive teach-related behavior which can be not being able to stop, excessive use, persistent thinking about technology, can’t put it down, needing more, and withdrawal when stop.
Date of Birth
MonthDayYear
Date
Approximately, in which age you started to use technology?
Age
Are you addicted any of these listed below:
TVInternetVideo gamesPornographyTextingFacebookOther social media
Do you participate any other activities apart from technology?
SportsMusicDanceHobbiesCraftsSchool/work/volunteer committeesDatingPartiesMeals outCoffeeRecreational outingsBarbecuesOther
Do you have any academic or work related problems?
GradesDrop-outSkipping classDetentionsProbationsFiringsOther
Please select if you suffer from any of the following mental health problems and developmental disorders?
DepressionAnxietyObsessive/compulsive disorder,AdhdAutismBipolar disorderSchizophreniaDevelopmental delayTantrumsAggressionDefianceLearning difficultiesOther
What kind of TV shows do you watch?
SportsCartoonsMoviesSitcomsViolenceSexualRealityNatureEducationalMusic/danceI don't watch any TV.Other
Please select the one(s) you are actively using:
Cell phoneTabletComputerGaming deviceOther
Do you have a home-based business?
YesNoOther
Do you watch fast paced content such as screen changes every 1-2 seconds?
YesNoOther
When do you use technology mostly?
right before bedwake up at night to use technologyduring mealsDuring the work/school timeDuring weekendsOn holidaysOther
Where do you use technology mostly?
In bedroom during nightIn restaurantsIn carIn bathroom (home/school/work)While watching TVWhile doing homeworkWhile with family/friendsOther
Why do you think you are using technology?
I feel lonelyI feel depressedI need an escapeI feel boredomI want to fit inIt feels ‘normal’I fear of face to faceOther
Do your parents or partner
Have rules regarding your use of entertainment technology?Supervise your use of entertainment technologyAddicted to technologyOther
How long do you use technology daily average?
Hours
At home during the week
At home on weekend or holidays
At school/work
Do you want to add something?
Please verify that you are human*
Should be Empty:

	Hours
At home during the week
At home on weekend or holidays
At school/work