| Rarely | Once in 3 Months | Monthly | Several Times per Month | Once per Week | Several Times per Week | Daily |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |
| 1 □ | 2 □ | 3 □ | 4 □ | 5 □ | 6 □ | 7 □ |