Problematic Consumption Survey
Help us understand your consumption habits and any challenges you may face.
Your Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Which of the following best describes the type of consumption you are concerned about?
*
Alcohol
Tobacco/Nicotine
Food/Binge Eating
Shopping/Spending
Online Activities (e.g., gaming, social media)
Other
How often do you engage in this type of consumption?
*
Daily
Several times a week
Weekly
Monthly
Rarely
On a scale of 1 to 10, how much do you feel this consumption negatively impacts your life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have tried to reduce or stop this consumption.
1
2
3
4
5
I feel guilty or ashamed about my consumption.
6
7
8
9
10
My consumption affects my relationships.
11
12
13
14
15
My work or studies have suffered due to this consumption.
16
17
18
19
20
I have experienced financial difficulties related to my consumption.
21
22
23
24
25
What triggers your consumption most often?
Stress or anxiety
Social situations
Boredom
Loneliness
Habit
Other
Have you ever sought help or support to address this consumption?
*
Yes
No
If yes, what type of support have you sought?
Professional counseling or therapy
Support groups
Family or friends
Online resources
Other
In your own words, please describe how this consumption has affected your daily life.
Would you be interested in receiving information or resources to help manage your consumption?
Yes
No
Maybe
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