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Questionnaire Name - A Place for Meditation

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1	Age?
	A- Below 15 (0)  B- 15 - 18 (0)  C- 19 - 23 (1)  D- 24 - 28 (5)  E- 29 - 35 (0)  F- 36 - 42 (0)  G- Above 42 (0)
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2	Gender?
	A- Male (0)  B- Female (6)
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3	Occupation?
	A- Executive/Managerial (2)  B- Professional(doctor,lawyer,etc.) (1)  C- Academic/Educator (0)  D- Computer Technical/Engineering (0)  E- Other Technical/Engineering (0)  F- Service/Customer Support (0)  G- Clerical/Administrative (0)  H- Sales/Marketing (0)  I- Tradesman/Craftsman (0)  J- College/Graduate Student (1)  K- K-12 Student (0)  L- Homemaker (0)  M- Self-employed/Own Company (1)  N- Unemployed, looking for work (1)  O- Retired (0)  P- Other (0)
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4	Where do you live?
	A- North London (1)  B- East London (4)  C- South London (1)  D- West London (0)  E- Other (0)
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5	Is this far from work?
	A- Yes (1)  B- No (4)
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6	How stressful do you find daily life?
	A- extremely stressful (0)  B- very stressful (1)  C- stressful (4)  D- a little stressful (0)  E- not stressful (1)
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7	How easy do you find it to shut off from the stresses of the day?
	A- extremely easy (0)  B- very easy (0)  C- easy (2)  D- not very easy (4)  E- difficult (0)
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8	What effects do these stresses have on your body?
	A- headaches (4)  B- back pain (2)  C- chest pain (0)  D- high blood pressure (0)  E- stomach upset (0)  F- trouble sleeping (6)
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9	What effects do these stresses have on your mind?
	A- anxiety (4)  B- restlessness (4)  C- irritability (6)  D- depression (1)  E- anger (1)  F- lack of focus (2)
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10	What effects do these stresses have on your behaviour?
	A- overeating (3)  B- undereating (0)  C- increased smoking (3)  D- drug or alcohol abuse (4)  E- social withdrawal (2)  F- relationship conflicts (1)
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11	What activities do you engage in to escape from daily stresses?
	A- gym (2)  B- sports (1)  C- socialising with friends (6)  D- watching tv (3)  E- shopping (3)  F- evening drinks (6)  G- cinema (3)  H- reading (3)
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12	Have you ever felt a desire for an alternative method of escape?
	A- Yes (5)  B- No (1)
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13	If there was a centre for meditation nearby, how likely would you be to use it?
	A- extremely likely (0)  B- very likely (2)  C- likely (3)  D- not likely (1)  E- never (0)
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14	What kind of facilities would you expect a meditation centre to provide?
	A- private meditation rooms (5)  B- group meditation rooms (5)  C- communal area (2)  D- cafe (4)  E- library (3)  F- shop (2)  G- outdoor space (5)  H- water feature (4)  I- bathing pool (2)  J- changing facilities (4)
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15	What materials would you like to see used for a meditation centre?
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