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These days, people find relief from their ils in a variety of different substances; some are freely available; others are prescribed, while others are illegal. Some drugs are politically correct, while others are not. What experience do YOU have in this area? For this survey, we are focusing on some of the more prominent controlled or addictive substances.

NOTE: ALL responses are completely confidential. Please answer honestly so we have the most accurate results.

Full Name:
Email Address:

1. In what form have you taken drugs? (check all that apply)
   - Drinking
   - Smoking
   - Eating
   - Sniffing
   - Pills
   - Injection - by a health professional
   - Injection - self
   - Inhalation
   - Absorbtion - skin
   - Other

2. How would you characterize your experience with Alcohol? No Answer Never tried it Have tried it but do not drink any longer Reformed alcoholic/no longer drink Beer only (daily) Beer only (weekly) Beer only (monthly) Beer only (rarely) Beer/Hard liquor (daily) Beer/Hard liquor (weekly) Beer/Hard liquor (monthly) Mostly wine/champagne (rarely) Mostly wine/champagne (daily) Mostly wine/champagne (weekly) Mostly wine/champagne (monthly) Mostly hard liquor (rarely) Mostly hard liquor (daily) Mostly hard liquor (weekly) Mostly hard liquor (monthly)

3. How would you characterize your experience with Marijuana? No Answer Never tried it Never have but would like to try it Tried it once Tried it a few times Smoked on occasion in the past but no longer Regularly smoked it in my youth but no longer Still smoke on rare occasions Still smoke occasionally Still smoke monthly Still smoke weekly Still smoke on a daily basis

4. Based on your experience with marijuana, what are your thoughts on its effects?
   No Answer Never smoked It's very relaxing; helps me deal with stress I use it for medicinal purposes It's good for social interaction It makes me paranoid/uncomfortable It enhances my creativity I use it to stimulate my appetite when appropriate It makes me hallucinate It enhances my senses It dulls my senses It makes me belligerent It doesn't seem to affect me Other

5. Based on your experience with cocaine, what are your thoughts on its effects?
   No Answer Never tried cocaine It's very relaxing; helps me deal with stress I use it for medicinal purposes It enhances my creativity It enhances my productivity It makes me hallucinate It enhances my senses It dulls my senses It is too addictive It makes me belligerent It doesn't seem to affect me Other

6. Based on your experience with alcohol, what are your thoughts on its effects?
   No Answer Never tried it It's very relaxing; helps me deal with stress I use it for medicinal purposes It's good for social interaction It makes me paranoid/uncomfortable It enhances my creativity It makes me hallucinate It enhances my senses It dulls my senses It makes me belligerent It doesn't seem to affect me Other

7. Has anyone in your family had an alcohol or drug problem?
   No Alcohol - one/both parents Alcohol - brother/sister Alcohol - someone else in family Alcohol - spouse Alcohol - former spouse Alcohol - son/daughter Drugs - one/both parents Drugs - brother/sister Drugs - someone else in family Drugs - spouse Drugs - former spouse Drugs - son/daughter Several people in my family have had alcohol problems Several people in my family have had drug problems Several people in my family have had alcohol & drug problems

8. Have you ever been arrested by the authorities relating to drug/alcohol use?
   No Answer No No - but have had a close call Yes - Alcohol (underage drinking) Yes - Alcohol (driving under the influence) Yes - Marijuana (possession) Yes - Marijuana (driving under the influence) Yes - Marijuana (distribution/dealing) Yes - Other drugs (possession) Yes - Other drugs (driving under the influence) Yes - Other drugs (distribution/dealing)

9. At what age did you try marijuana (if appropriate)?
   No Answer I have never tried marijuana Under 10 11-13 14-15 16-17 18-21 22-25 26-30 31-40 40+

10. At what age did you first consume alcohol (if appropriate)?
    No Answer I have never consumed alcohol Under 10 11-13 14-15 16-17 18-21 22-25 26-30 31-40 40+

11. What best describes your attitude towards drugs & alcohol?
    All drugs & alcohol should be freely available All drugs & alcohol should be more tightly regulated Things should stay the way they are Education is the key to dealing with drug/alcohol problems This is a personal psychological issue more than a sociological issue We need more stringent penalties against users We need more stringent penalties against dealers Certain drugs such as marijuana should be legalized We should bomb drug developing countries back to the stone age

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