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Healthy Mind

Smart + Strong wants to hear about your experiences with mental illness. Please take the following confidential survey to help us better understand your concerns and needs.
 
1. Have you or a family member ever been diagnosed with a mental illness?
I was diagnosed with a mental illness
A family member was diagnosed with a mental illness
Both a family member and I were diagnosed with a mental illness
 
2. If a family member was diagnosed with a mental illness, what is his or her relationship to you? (Check all that apply.)
Husband/wife/partner
Son or daughter
Mother or father
Other family member
No family member was diagnosed with a mental illness
 
3. How long have you or a family member been diagnosed with the illness?
Less than six months
Six months to just under one year
One to just under five years
More than five years
 
4. Which of the following mental illnesses were you or a family member diagnosed with? (Check all that apply.)
Depression (unipolar or dysthymia)
Anxiety disorder
Panic disorder
Bipolar disorder
Obsessive-compulsive disorder
Hyperactivity disorder
Schizophrenia
 
5. Were you or a family member prescribed medicine for the illnesses?
Yes
No
 
6. If you are taking medicine, which kinds? (Check all that apply.)
Antidepressant (e.g. Prozac, Zoloft, Wellbutrin)
Antianxiety medication (e.g. Paxil, Ativan, Klonopin)
Mood stabilizer/atypical antipsychotic (e.g. lithium, Geodon, Abilify)
Stimulant (e.g. Ritalin, Adderall, Strattera)
Sleep medication (e.g. Ambien, Sonata, Trazodone)
I don't know
 
7. Have you or a family member ever had side effects from the medication(s)?
Yes
No
 
8. If you or a family member has had side effects, which ones? (Check all that apply.)
Drowsiness
Upset stomach, nausea or vomiting
Unable to get to sleep or stay asleep
Involuntary movements of your mouth
Jerkiness in your movement
Feeling "flat" or uninterested in things you usually enjoy
Feeling speedy or revved up
Other: 
 
9. Do you ever have trouble taking your medication because you don't like taking it or you forget to take it?
Yes
No
 
10. Are you or a family member seeing a psychotherapist?
Yes
No
 
11. What is your gender?
Male
Female
Transgender
Other
 
12. What is your sexual orientation?
Straight
Gay/lesbian
Bisexual
Other
 
13. What is your ethnicity? (Check all that apply.)
American Indian or Alaska Native
Arab or Middle Eastern
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
(Please specify.) 
 
14. What is the highest level of education attained?
Some high school
High school graduate or GED
Some college or an associate's degree
Bachelor's degree or higher
 
15. What is your ZIP code?
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