Survey:  Are Alcohol, Tobacco, Substances, and/or Gambling
Factors in Your Life?

Please fill out this form as honestly as possible. 
The form is completely confidential and anonymous.

1.  Are you (check one):    male         female        

2.  How old are you?   

3.  Have you ever smoked a cigarette?        yes     no

If you answered yes...

How old were you the first time you tried a cigarette? 

Do you still smoke cigarettes?    yes     no

In the past month, how many times have you smoked a cigarette? 

4.  How much do you think people harm themselves if they use tobacco regularly (select one option from the drop-down menu)?   no harm very little harm some harm a lot of harm do not know

5. Have you ever tried drinking alcohol to feel high or drunk?  yes     no

If you answered yes...

How old were you the first time you drank alcohol? 

Do you still drink alcohol?  yes     no

In the past month, how many times have you consumed alcohol to feel high or drunk? 

6.  How much do you think people harm themselves if they use alcohol regularly (choose one option from the drop-down menu)?    no harm very little harm some harm a lot of harm do not know

7.  Have you tried "huffing" or inhalants?  yes     no

If you answered yes...

How old were you the first time you tried huffing or inhalants? 

Do you still use inhalants?  yes     no

In the past month, how many times have you huffed or used inhalants? 

8.  How much do you think people harm themselves if they "huff" or use inhalants (choose one option from the drop-down menu)?:   no harm very little harm some harm a lot of harm do not know

9.  Have you ever tried marijuana?  yes     no

If you answered yes...

How old were you the first time you tried marijuana? 

Do you still use marijuana?  yes     no

How many times in the past month have you used marijuana? 

10.  How much do you think people harm themselves if they use marijuana regularly (choose one option from the drop down menu)?   no harm very little harm some harm a lot of harm do not know

11.  Have you ever gambled for money?  yes     no

If you answered yes...

How old were you the first time you gambled for money? 

Do you still gamble for money?  yes     no

In the past month, how many times have you gambled for money? 

What is the largest amount of money that you have bet? 

What is the largest amount of money that you have won? 

What is the largest amount of money that you have lost? 

12. Have any of your friends gambled for money?  yes     no

13. How much do you think people harm themselves if they gamble regularly (choose one option from the drop-down menu)?    no harm very little harm some harm a lot of harm do not know

Thank you for sharing your opinions and your voice!  Please review your answers and click the "submit" button below if you have no changes.  If you would like to change your answers, click the "reset" button and start again.