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1. What is your current age? |
|
|
| A) 18 years old |
0 |
0% |
| B) 17 years old |
0 |
0% |
| C) 16 years old |
0 |
0% |
| D) 15 years old |
0 |
0% |
| E) 14 years old |
0 |
0% |
| F) 13 years old |
1 |
100% |
| G) younger than 12 |
0 |
0% |
| H) Older than 7 |
0 |
0% |
| Total Number of Choices | 1 | |
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2. What is your gender? |
|
|
| A) Female |
1 |
100% |
| B) Male |
0 |
0% |
| Total Number of Choices | 1 | |
|
3. Have you ever taken a puff (drag) from a cigarette before? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
1 |
100% |
| C) Yes more than five times |
0 |
0% |
| D) No, I have never taken a puff (drag) from a cigarrette |
0 |
0% |
| E) Never, I do not smoke |
0 |
0% |
| Total Number of Choices | 1 | |
|
4. Have you ever tried cigarette smoking, after taking one or two puffs (drags)? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
1 |
100% |
| D) No, I have never tried cigarette smoking |
0 |
0% |
| E) Never, I do not smoke |
0 |
0% |
| Total Number of Choices | 1 | |
|
5. Have you ever smoked at least one cigarette every day for 30 days? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not smoke |
0 |
0% |
| Total Number of Choices | 1 | |
|
6. Have you ever had a drink of an alcoholic beverage such as beer, wine, or liquor more than three times in your life? If yes about how many times? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, more than three times |
1 |
100% |
| D) No |
0 |
0% |
| E) Never, I do not drink alcohol |
0 |
0% |
| Total Number of Choices | 1 | |
|
7. Have you ever drank beer, wine, or liquor when you were not with your parents or other adults in your family? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, every day |
0 |
0% |
| C) Yes, a few times a week |
0 |
0% |
| D) Yes a few times a month |
0 |
0% |
| E)Yes, at least once a year |
1 |
100% |
| F) No |
0 |
0% |
| G) Never, I do not drink alcohol |
0 |
0% |
| Total Number of Choices | 1 | |
|
8. Have you ever gone to school drunk? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not drink alcohol |
0 |
0% |
| Total Number of Choices | 1 | |
|
9. Have you ever brought alcohol to school with the specified purpose of getting drunk? If yes how many times? |
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|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not drink alcohol |
0 |
0% |
| Total Number of Choices | 1 | |
|
10. Have you ever tried marijuana before? If yes how many times? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not use drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
11. How old were you when you first tried marijuana? |
|
|
| A) 18 years old |
0 |
0% |
| B) 17 years old |
0 |
0% |
| C) 16 years old |
0 |
0% |
| D) 15 years old |
0 |
0% |
| E) 14 years old |
0 |
0% |
| F) 13 years old |
0 |
0% |
| G) younger than 10 years old |
0 |
0% |
| H) Older than seven years old |
0 |
0% |
| I) Does not apply |
1 |
100% |
| Total Number of Choices | 1 | |
|
12. Have you ever tired any other types of drugs? |
|
|
| A) Yes |
0 |
0% |
| B) No |
1 |
100% |
| Total Number of Choices | 1 | |
|
13. If you have tried other drugs before,which other drugs have you tried? Place a circle around the drugs you have tried. |
|
|
| A) Cocaine |
0 |
0% |
| B) Cocaine Powder |
0 |
0% |
| C) Crack Cocaine |
0 |
0% |
| D) Inhalents (glue and solvents) |
0 |
0% |
| E) LSD |
0 |
0% |
| F) PCP |
0 |
0% |
| G) Ecstasy |
0 |
0% |
| H) Mushrooms |
0 |
0% |
| I) Speed |
0 |
0% |
| J) Ice |
0 |
0% |
| K) Heroin |
0 |
0% |
| L) Pills |
0 |
0% |
| M) Perscription Medication (someone elses) |
1 |
50% |
| N) Does not apply |
1 |
50% |
| Total Number of Choices | 2 | |
|
14. How old were you when you first tried these (this) drug(s)? |
|
|
| A) 18 years old |
0 |
0% |
| B) 17 years old |
0 |
0% |
| C) 16 years old |
0 |
0% |
| D) 15 years old |
0 |
0% |
| E) 14 years old |
0 |
0% |
| F) 13 years old |
0 |
0% |
| G) younger than 12 |
0 |
0% |
| H) Older than 7 |
0 |
0% |
| I) Does not apply |
1 |
100% |
| Total Number of Choices | 1 | |
|
15. Have you ever been high on drugs while at school? If yes how many times? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not use drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
16. Have you ever brought drugs to school with the intention of getting high at school? If yes how often? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not use drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
17. Have you ever been treated for drug or alcohol abuse? |
|
|
| A) Yes |
0 |
0% |
| B) Yes, once or twice |
0 |
0% |
| C) Yes, a few times |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not abuse drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
18. Are you currently using drugs? If yes how frequently? |
|
|
| A) Yes, daily |
0 |
0% |
| B) Yes, a few times a week |
0 |
0% |
| C) Yes, occaissionally |
0 |
0% |
| D) No |
1 |
100% |
| E) Never, I do not use drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
19. Do you currently spend time with people who are either using or have used drugs? |
|
|
| A) Yes |
0 |
0% |
| B) No |
0 |
0% |
| C) Sometimes |
1 |
100% |
| D) Never, I do not spend time with people who use drugs |
0 |
0% |
| Total Number of Choices | 1 | |
|
20. If you are currently abusing drugs and /or alcohol and you have never been treated for drug and/or alcohol abuse would you like to receive treatment? |
|
|
| A) Yes |
0 |
0% |
| B) No |
1 |
100% |
| C) Maybe |
0 |
0% |
| D) I am not sure I need time to think about it |
0 |
0% |
| Total Number of Choices | 1 | |
