Impact of Isolation on Life Survey
Help us understand how periods of isolation have affected different aspects of your life. Your responses are confidential and will be used for research and support purposes.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
What is your current living situation?
*
Please Select
Living alone
With family
With roommates
Other
How long have you experienced periods of isolation?
*
Please Select
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
How often do you feel lonely during isolation?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Please rate the impact of isolation on the following aspects of your life:
*
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Emotional well-being
1
2
3
4
Physical health
5
6
7
8
Social relationships
9
10
11
12
Work or academic performance
13
14
15
16
Sleep quality
17
18
19
20
Which coping strategies have you used during isolation? (Select all that apply)
Staying connected with friends/family online
Exercise or physical activity
Creative hobbies (art, music, writing, etc.)
Professional support (therapy, counseling)
Other
Have you noticed any positive changes in your life due to isolation?
*
Yes
No
Not sure
Please describe any significant experiences or changes you have noticed in yourself during isolation.
Email Address (optional, if you wish to receive updates about this research)
example@example.com
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