Preliminary survey design

The following is a rough idea of what I will ask in my survey. I'm trying to create a computer program that will create a database from the provided answers, as well as allow users to digitally "sign" their surveys. I welcome all feedback and ideas, either in formatting of the quiz or in questions asked.

Page 1: Adobe acrobat signature consent page
Page 2: Demographics:
• Gender
• Age
• Average household income
• Highest level of education personally achieved
• Highest level of education achieved by parent
• Metro area
• Citizenship
Page 3: Vitals—internet usage (in hours)
• How much time to you spend online?
• How much of this time is spent on eating disorder-related websites?
• What are your favorite eating disorder websites?
• Have you visited pro-ana/mia sites?
Page 4: Vitals: personal internet
• What do you use for inspiration?
• Which of the following are on your website?
o Stats
o Pictures of yourself at various weights
o Thinspiration
o Quotations
o Tickers
o Food diary
Page 5: Personal stats
• High weight
• Low weight
• Current weight
• Goal weight
• Goal reason
• Height
• Which of the following do you do?
Restrict
Vomit
Exercise
Laxatives
Medication (what kind?)
Pick certain foods
Fast
Add your own
Page 6: History
• Diagnosis
• Was this diagnosis rofessional or personal?
• What age did you start developing food issues?
• Why?
Teased
Wanted to look good for an event
Write your own
• Anyone else in your family with an ED?
• Seen a doctor?
• How long?
• Been hospitalized?
• Been in a group?
• In recovery?
• How long?
• Medical problems related to ED: osteoporosis, hair loss, stomach problems, heart palpitations, etc.
Page 7A: Pro-ana/mia
• Number of visits in past week
• In past month?
• What have you learned: restricting, covering, exercising?
• What do you think the purpose is?
• If in therapy, does your therapist know about your web visits?
• Volunteer for phone interview?
Page 7 B: Pro-recovery
• Number of visits in past week
• In past month?
• What do you think the purpose is?
• If in therapy, does your therapist know about your web visits?
• Volunteer for phone interview?