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