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Drug Survey

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.

  1. What substances have you tried at least once?(check all that apply)
    - Caffeine (Coffee/Tea/Soft Drinks)
    - Alcohol
    - Marijuana
    - Nicotine/Tobacco
    - Cocaine
    - Hashish
    - LSD/Acid
    - Valium
    - PCP/Angel Dust
    - Crack
    - Crank
    - Heroin
    - Morphine
    - Ecstasy
    - Mushrooms
    - Peyote
    - Soma
    - Prozak
    - Demerol
    - Nitros Oxide
    - Methamphetamines
    - Amyl Nitrate
    - Petroleum products/industrial chemicals (glue, cleaning agents, etc.)
    - Diet Pills
    - Other Painkillers
    - Other - Steroids
    - Other - Stimulants
    - Other - Depressants
    - Other - Psychoactive
    - Other - Inhalants
    - Other - Allergy Medication
    - Other - Prescription
    - Other - Non-Prescription
    - Other - Not Listed

  2. 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

  3. How would you characterize your experience with Alcohol?

  4. How would you characterize your experience with Marijuana?

  5. Do you believe any of the following substances should be legalized (or stay legal where appropriate)?(Check all that apply)
    - Caffeine (Coffee/Tea/Soft Drinks)
    - Alcohol
    - Marijuana
    - Nicotine/Tobacco
    - Cocaine
    - Hashish
    - LSD/Acid
    - Valium
    - PCP/Angel Dust
    - Crack
    - Crank
    - Heroin
    - Morphine
    - Ecstasy
    - Mushrooms
    - Peyote
    - Soma
    - Prozak
    - Demerol
    - Nitros Oxide
    - Methamphetamines
    - Amyl Nitrate

  6. Based on your experience with marijuana, what are your thoughts on its effects?

  7. Based on your experience with cocaine, what are your thoughts on its effects?

  8. Based on your experience with alcohol, what are your thoughts on its effects?

  9. Has anyone in your family had an alcohol or drug problem?

  10. Have you ever been in rehabilitation (including any 12-step programs) for a drug/alcohol habit?

  11. Have you ever been arrested by the authorities relating to drug/alcohol use?

  12. At what age did you try marijuana (if appropriate)?

  13. At what age did you first consume alcohol (if appropriate)?

  14. What are your thoughts on drug testing?

  15. Have you ever been tested for drugs by your employer?

  16. What best describes your attitude towards drugs & alcohol?

  17. What are your thoughts on drugs and drug usage? Enter a few sentences; do not press ENTER unless you're ready to submit your entire survey.

Thanks very much for participating in the survey!

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