Drug Use Inquiry Form
Please complete this confidential survey to help us understand your drug use patterns and experiences.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Email Address
*
example@example.com
Which of the following substances have you used in the past 12 months? (Select all that apply)
*
Alcohol
Cannabis (Marijuana)
Prescription drugs (used non-medically)
Stimulants (e.g., cocaine, amphetamines)
Opioids (e.g., heroin, fentanyl)
Hallucinogens (e.g., LSD, mushrooms)
Other
How often do you use the selected substances?
*
Rows
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Alcohol
1
2
3
4
5
Cannabis
6
7
8
9
10
Prescription drugs
11
12
13
14
15
Stimulants
16
17
18
19
20
Opioids
21
22
23
24
25
Hallucinogens
26
27
28
29
30
Other
31
32
33
34
35
At what age did you first use any of these substances?
*
What are your main reasons for using these substances?
*
Curiosity
Peer pressure
Stress relief
Recreation/fun
Medical reasons
Other
Have you experienced any negative consequences as a result of your drug use?
*
Health problems
Legal issues
Relationship issues
Problems at work/school
Financial difficulties
None
How would you rate the impact of your drug use on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Have you ever tried to reduce or stop using any of these substances?
*
Yes
No
Are you interested in receiving support or information about reducing or stopping drug use?
*
Yes
No
Maybe
Please share any additional comments or concerns about your drug use.
Submit
Should be Empty: