Mental and Physical Health Questionnaire for University Students
　Tohoku University provides support so that students may lead a mentally and physically healthy university life. This survey is part of such efforts.

　(1) To whom: All students enrolled at Tohoku University
　(2) For what: a) To understand your physical and mental conditions, and b) To provide individual support based on the results of this survey.

    All respondents' personal information will be kept strictly confidential.   Participation is optional, and you do not have to answer any questions that may make you feel uncomfortable. 
　Results from this questionnaire will be published. In the event, all personal information will be kept anonymous.
　By answering the questionnaire, it will be considered that you agreed to the above terms. 

Tohoku University Student Life Council; Center for Counseling and Disability Services, Tohoku University

＜Inquiries about this Questionnaire＞
Center for Counseling and Disability Services
Counseling Office
Tel: 022-795-7833 (Japanese only)
E-mail: gakuso@ihe.tohoku.ac.jp

1. Name *
2. Student ID *
3. Contact Information①（Telephone No.）
4. Contact Information②（E-mail: DCmail address）
5. Gender
6. Are you an international student?
7. Department①（Faculty / Graduate School）
8. Department②（Curriculum）
9. Department③（Year of Study）
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