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  2. 2011
  3. October
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  5. treatment services
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1) Year of study:
 
Freshman
 
Sophomore
 
Junior
 
Senior
 
 
 
2) Approximate cumulative GPA:
 
3.6-4.0
 
3.1-3.5
 
2.6-3.0
 
2.1-2.5
 
2.0 or below
 
 
 
3) Age:
   
 
 
 
4) Gender:
 
Male
 
Female
 
 
 
5) Number of siblings (brothers and sisters):
   
 
 
 
6) Living arrangements: Where
 
On campus
 
Off campus
 
 
 
7) Living arrangements: With whom (Select all that apply)
 
Both parents
 
Mother only
 
Father only
 
Extended family
 
Guardian
 
Friends
 
Roommate
 
Spouse
 
Other
 

 
 
8) How often have you used the following substances non-medically?
Never Once/twice Monthly Weekly Daily/almost daily
Tobacco products (cigarettes, shisha)
Cannabis (marijuana, hashish, bango)
Alcoholic beverages (beer, wine, spirits)
Ecstasy
Sedatives (sleeping pills, valium, rohypnol)
Opioids (tramadol, heroin, codeine, morphine)
Cocaine
Inhalants (glue, petrol, paint thinners)
Multiple substance use
Other
 
 
 
9) What mode of intake do you use with these substances? (Select all that apply)
 
Orally
 
Smoking
 
Inhaling
 
Snorting
 
Injecting
 
Other
 

 
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