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  1. How recently, if ever, have you taken the following PRESCRIPTION DRUGS not prescribed to you or only for the experience or feeling it caused even one time: (DARKEN ONE BUBBLE FOR EACH LINE: a-e.)

    Never heard of/Never used it Used at least once in the Past Month Used at least once Since School Began in the Fall Used at least once In Your Lifetime
    a. Codeine cough syrup (Lean, Nods, AC/DC)?
    b. OxyContin, Percodan, Percocet, Oxycodone, Vicodin, Lortab, Lorcet, or Hydrocodone?
    c. Valium, Diazepam, Xanax, or other benzodiazepines?
    d. Adderall, Ritalin, Dexedrine, Concerta, or Focalin?
    e. Any other prescription drug not listed above?


  2. How recently, if ever, have you taken the following OVER-THE-COUNTER DRUGS only for the experience or feeling it caused even one time:

    Never heard of/Never used it Used at least once in the Past Month Used at least once Since School Began in the Fall Used at least once In Your Lifetime
    a. DXM, Triple C’s, Skittles, or Coricidin?


  3. IN THE PAST 30 DAYS, how many times, if any, have you used: (DARKEN ONE BUBBLE FOR EACH LINE: a-f.)

    Never heard of/Never used it 1-2 Times 3-10 Times 11+ Times
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (whiteout, spray paint, glue, gas, etc.) to get high?
    d. Marijuana?
    e. Cocaine (not crack)?
    f. Crack??


  4. About how many of your close friends use: (DARKEN ONE BUBBLE FOR EACH LINE: a-d.)

    Never heard of/None A few Some Most All
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (whiteout, spray paint, glue, gas, etc.) to get high?
    d. Marijuana?


  5. How old were you when you first used: (DARKEN ONE BUBBLE FOR EACH LINE: a-l.)

    Never used it 8 or younger 9 10 11 12 13 14 15 16 17 18 or older
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (whiteout, spray paint, glue, gas, etc.) to get high?
    d. Marijuana?
    e. Cocaine (not crack)?
    f. Crack?
    g. Blamaril?
    h. Steroids
    i. Ecstasy?
    j. Heroin (black tar, cheese, chiva, brown heroin)?
    k. Methamphetamine (speed, crystal meth, ice, or crank)?
    l. Synthetic Marijuana (spice, K2)?


  6. If you wanted some, how difficult would it be to get: (DARKEN ONE BUBBLE FOR EACH LINE: a-l.)

    Never heard of it Impossible Very difficult Somewhat difficult Somewhat easy Very easy
    a. Tobacco?
    b. Alcohol?
    c. Inhalants (whiteout, spray paint, glue, gas, etc.) to get high?
    d. Marijuana?
    e. Cocaine (not crack)?
    f. Crack?
    g. Blamaril?
    h. Steroids
    i. Ecstasy?
    j. Heroin (black tar, cheese, chiva, brown heroin)?
    k. Methamphetamine (speed, crystal meth, ice, or crank)?
    l. Synthetic Marijuana (spice, K2)?