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How old are you?
 
15-18
 
19-25
 
26-30
 
30+
 
 
 
Gender?
 
Male
 
Female
 
Other
 
 
 
Do you drink alcohol?
 
Yes
 
No
 
Sometimes
 
 
 
If so, how often?
 
Less than once a week
 
Once or twice a week
 
3 or more times a week
 
 
 
Do you smoke marijuana?
 
Yes
 
No
 
Sometimes
 
 
 
If so, how often?
 
Less than once a week
 
Once or twice a week
 
3 or more times a week
 
 
 
Do you use other substances?
 
Yes
 
No
 
Sometimes
 
 
 
If so, how often?
 
Less than once a week
 
Once or twice a week
 
3 or more times a week
 
 
 
Do you go to class everyday?
 
Yes
 
No
 
Sometimes
 
 
 
Do you get your schoolwork done on time?
 
Yes
 
No
 
Sometimes