Daily Caffeine Intake Survey
Help us understand your daily caffeine habits by answering the following questions.
What is your age?
*
What is your gender?
*
Male
Female
Non-binary
Prefer not to say
Other
On average, how many caffeinated drinks do you consume per day?
*
Which of the following caffeinated beverages do you regularly consume? (Select all that apply)
*
Coffee
Tea
Energy Drinks
Soda/Cola
Iced Tea
Chocolate (drinks or bars)
Other
At what times do you usually consume caffeinated beverages? (Select all that apply)
*
Morning (6am-12pm)
Afternoon (12pm-5pm)
Evening (5pm-9pm)
Night (after 9pm)
How important is caffeine to your daily routine?
*
Not at all important
1
2
3
4
Extremely important
5
1 is Not at all important, 5 is Extremely important
How do the following effects relate to your caffeine consumption? Please rate each statement.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Caffeine helps me stay alert
1
2
3
4
5
Caffeine improves my mood
6
7
8
9
10
Caffeine disrupts my sleep
11
12
13
14
15
I feel jittery after caffeine
16
17
18
19
20
I feel withdrawal symptoms without caffeine
21
22
23
24
25
How concerned are you about your daily caffeine intake?
*
1
2
3
4
5
Have you ever tried to cut down on your caffeine consumption?
*
Yes
No
If yes, what strategies did you use to reduce your caffeine intake? (If not applicable, leave blank)
Please share any additional comments or thoughts about your caffeine habits.
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