Survey On Drug Abuse Among Youngster
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- Pages: 4
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
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
1/4
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
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
3/4
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
Powered by
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
4/4
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
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
1/4
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
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
3/4
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
Powered by
https://docs.google.com/forms/d/1pM4MWUX6q2ujjcPK9YK37waBGfkd6zsy0lkctBc1xSQ/edit
4/4
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