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3/31/2019 Survey on Drug Abuse

Survey on Drug Abuse


This questionnaire is part of an study on alcohol, drug and tobacco use among students. The
information you give will contribute to a better understanding of young people like yourself. The
answer you give will be kept private.

* Required

1. How old are you? *


Mark only one oval.

17 years old
18 years old
19 years old
20 years old
21 years old
22 years old or above

2. What is your sex? *


Mark only one oval.

Female
Male
Prefer not to say

Other:

3. which grade your are in ? *


Mark only one oval.

O Grade
A+ grade
A grade
B+ grade
B grade
RA

The following questions are about CIGARETTE SMOKING.


4. How many times IN YOUR LIFE have you smoked cigarettes? *
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

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3/31/2019 Survey on Drug Abuse

5. How many times in THE LAST 12 MONTHS have you smoked cigarettes? *
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


No of Occasions

6. How many times in THE LAST 30 DAYS have you smoked cigarettes? *
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of Occasions

The next question are about ALCOHOLIC BEHAVIOR, including


beer, wine and spirits.
7. how many times IN YOUR LIFE have you had any alcoholic beverage to drink ( more than
just a few sips)? *
Mark only one oval per row.

0 times 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

8. How many times in THE LAST 12 MONTHS have you had any alcoholic beverage to drink (
more than just a few sips)? *
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

9. How many times in THE LAST 30 DAYS have you had any alcoholic beverage to drink (
more than just a few sips)?
Mark only one oval per row.

0 times 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

The next question ask about some other Drugs


10. Have you ever heard of any of the following drugs?(mark all the box that apply) *
Check all that apply.

Tranquillizes or sedatives [give names that apply]


cannabis (grass, pot) or hashish (hash, hash oil)
Amphetamines (uppers, pep pills, bennies, speed)
Ecstasy
LSD
Relevin
Crack
Cocaine
Heroin

https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit 2/4
3/31/2019 Survey on Drug Abuse

11. How many times IN YOUR LIFE have you used any of the following drugs? *
Cannabis ,Opiates ,Sedative and hypnotics
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

12. how many times IN THE LAST 12 MONTHS have you used any of the following drugs? *
Cannabis ,Opiates ,Sedative and hypnotics
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

13. how many times IN THE LAST 30 DAYS have you used any of the following drugs? *
Cannabis ,Opiates ,Sedative and hypnotics
Mark only one oval per row.

0 time 1-2 3-5 6-9 10-19 20-39 40 or more


Number of occasions

14. Have you used drugs other than those required for medical reasons? *
Mark only one oval.

Yes
No

15. Do you abuse more than one drug at a time *


Mark only one oval.

Yes
No

16. Have you neglected your family because of your use of drug?
Mark only one oval.

Yes
No

17. Have you engaged in illegal activities in order to obtain drugs?


Mark only one oval.

Yes
No

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3/31/2019 Survey on Drug Abuse

18. why did you start using drugs?


Check all that apply.

Teenagers curiosity
Joy-seeking
Somatic diseases
psychological disorder
Lack of Knowledge about complication of drugs
Positive attitude towards drug abuse
Low self-confidence
To eliminate shyness
Parents divorce
Lack of amusement facilities
Disability in resolving routine problems
Having strict parents
Presence of an addicted person in the Friends offer Family disputes Access to drugs
Lack of access to consultation centers
Low cost of drugs
Have a free time
Presence of an addicted person
residential/educational place
other

19. How to you use the drug?


Mark only one oval.

sniff (via nose)


Smoke
Oral
Injection
Others

20. Have you have a hangover?


Mark only one oval.

Yes
No

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