Screen Time Effects Survey Form
Help us understand how screen time impacts your daily habits and well-being. Please answer all questions honestly.
How many hours per day do you typically spend on screens (phone, computer, tablet, TV)?
*
Less than 2 hours
2-4 hours
4-6 hours
6-8 hours
More than 8 hours
Which devices do you use most frequently for screen time? (Select all that apply)
*
Smartphone
Laptop/Desktop
Tablet
Television
Other
How often do you use screens within one hour before going to sleep?
*
Never
Rarely
Sometimes
Often
Always
To what extent do you agree with the following statements about your screen time?
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Screen time affects my sleep quality
1
2
3
4
5
Screen time impacts my mood
6
7
8
9
10
Screen time reduces my physical activity
11
12
13
14
15
Screen time affects my productivity
16
17
18
19
20
Screen time impacts my social interactions
21
22
23
24
25
On a scale of 1 to 10, how would you rate your overall well-being?
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How often do you take breaks from screens during long usage sessions?
*
Never
Rarely
Sometimes
Often
Always
How would you describe your sleep quality over the past month?
*
Very poor
Poor
Average
Good
Excellent
How satisfied are you with the balance between your screen time and other daily activities?
*
1
2
3
4
5
Have you made any efforts to reduce your screen time in the past 6 months?
*
Yes
No
If you have any additional comments about your screen time habits or its effects, please share them below.
Submit Survey
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