Caffeine Consumption Questionnaire 1. Age: 2. Gender Male Female 3. What is your race (optional, if two or more, select all that apply)? American Indian and Alaska Native Asian African American Native Hawaiian and Other Pacific Islander White Other, please specify    4. How many average hours of sleep do you get on a weekday? 10+ 8-9 6-7 4-5 <4 5. On average, how many hours of homework do you have a night? 6. Do you drink caffeinated beverages? Yes No 7. If no caffeinated beverages, why not? bad taste unhealthy no need to other, please specify    8. How many caffeinated beverages do you drink in a day? 3 2 1 Other, please specify    9. How many caffeinated beverages do you drink in a week? 10. Why do you drink caffeinated beverages? stay awake like the taste sugar rush nothing else to drink social other, please specify    11. Do you consume more caffeine during the weekend? Yes No 12. Do you drink energy drinks? Yes No 13. If no energy drinks, why not? bad taste unhealthy no need to other, please specify    14. If no, then based on the following names of drinks, which would you choose (check one)? Battery Cocaine Energy Drink Diesel Full Throttle Red Bull SoBe 15. If yes, which do you prefer (SoBe, Red Bull, Cocaine, etc.)? 16. How many energy drinks in a day? 3 2 1 other, please specify    17. How many energy drinks in a week? 18. Why do you drink energy drinks? stay awake like the taste sugar rush nothing else to drink other, please specify    19. Do you drink any caffeinated beverages while studying for a test/exam? Yes No 20. Do you think it helped? Yes No 21. How many drinks do you consume per study session? 3 2 1 other, please specify    22. Do you feel that you function as well without caffeine? Yes No 23. A plain, brewed 8 oz cup of coffee contains about 110 mg of caffeine, how much caffeine do you think is in X? Coca-Cola Classic, 12 oz (range 0-300mg):    24. Diet Coke, 12 oz (range 0-300mg):    25. Red Bull, 8.3 oz (range 0-300mg):    26. Cocaine Energy Drink, 8.4 oz (range 0-300mg):    27. Green Tea, 8 oz (range 0-300mg):    28. Do you drink caffeinated beverages within 20 minutes of _____ (check all that apply)? sleeping eating physical activities studying other, please specify    29. True or False: Caffeine can take effect in as little as 5 minutes. true false 30. What one word would you associate caffeine with? 31. Has anyone ever told you that you drink too many caffeinated beverages? Yes No 32. Do you think you consume too much caffeine? Yes No 33. After not drinking caffeinated beverages, do you exhibit withdrawal symptoms such as headache, insomnia, fatigue, dizziness, nausea, vomiting? Yes No 34. In general, would you rather drink a caffeinated beverage or drink water? caffeinated beverage water 35. Would you characterize your drinking caffeinated beverages as a habit, addiction, or neither? 36. Do you consume caffeine pills? Yes No 37. After being aware of the many side effects of abusing caffeine, such as anxiety, insomnia, headache, tremors, poor concentration, etc., would you still drink as much? Yes No 38. If not, would you still drink at all? Yes No 39. Do you drink caffeinated beverages to "get going" in the mornings? Yes No 40. True or False: Caffeine is America’s most popular drug true false Powered by CreateSurvey