First Name
Last Name
Do you live in a Rural, Urban or Coastal area?  
Age group  
Sex  
Level of Education  
State  
Email Address
Do you identify with having a religion?  
Do you or anyone in your immediate family suffer from anxiety or phobias?  

Do you regularly... ?

Exercise (at least 30 minute walk 3 times a week)
Have trouble sleeping
Meditate, do yoga or Tai Chi
Eat junk food (be honest!)
Eat processed foods, such as white bread, chips
Smoke
Drink coffee/tea/energy drinks
Watch scary videos
Watch the news
Drink moderate amounts of alcohol (one-two standard drinks a day)
Drink alcohol heavily (more than two standard drinks a day)
Take prescription drugs
Take other drugs
Own a pet (dog, cat, fish, bird, ferret etc)
Regularly take part in extreme sports such as bungee jumping, skydiving or white water rafting

Submit >>