[step_start "About You"]

    About You

    [progressbar type:numbers]

    Have you drunk any alcohol in the last year?

    Please select yes or no.

    YesNo

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    [step_finish]

    [group substanceabuse]
    [step_start "Substance Use"]

    Substance Use

    [progressbar type:numbers]

    In the past four weeks (28 days) have you used drugs other than alcohol.

    This includes illicit drugs and pharmaceutical medications (e.g. sleeping pills, pain killers). It does not include medication that you take as prescribed by your doctor.

    YesNo

    Of the following substances, select the ones you have used and how many days In the past four weeks (28 days) you have you used them.

    Yes

    No

    Days Used

    Alcohol

    YesNo

    Cannabis (e.g. marijuana, pot, grass, hash, synthetic cannabis etc)

    YesNo

    Methamphetamine (e.g., ice, speed, base)

    YesNo

    Other amphetamine type stimulants (e.g. MDMA /ecstasy, diet pills etc)

    YesNo

    Prescribed sedatives or sleeping pills (e.g. benzodiazepines, xanax, valium, serapax, rohypnol, stilnox etc)

    YesNo

    Non-prescribed benzodiazepines

    YesNo

    Prescribed Opioids (e.g. methadone/buprenorphine)

    YesNo

    Non-prescribed Opioids (e.g. heroin, codeine, methadone, oxycodone, morphine, fentanyl etc)

    YesNo

    Cocaine

    YesNo

    Inhalants (e.g. nitrous, glue, petrol, paint thinner, Amyl etc)

    YesNo

    Hallucinogens (e.g. LSD, acid, mushrooms, PCP, ketamine, synthetic hallucinogens etc)

    YesNo

    GHB

    YesNo

    Tobacco

    YesNo

    Other substances (e.g. steroids caffeine/energy drinks, new and emerging drugs etc)

    YesNo

    Have you injected drugs in the past four weeks?

    YesNo

    Did you inject with equipment used by someone else?

    YesNo

    [prev "< Back"]
    [next "Next >"]

    [step_finish]
    [/group]

    [group alcoholabuse]
    [step_start "Alcohol Usage"]

    Alcohol Use

    [progressbar type:numbers]

    The following questions will give us a picture of your recent alcohol use. Please select the response that best describes your drinking. If you haven’t been drinking alcohol you don’t need to answer the questions.

    1-2

    3-4

    5-6

    7-9

    10+

    How many drinks containing alcohol do you have on a typical day when you are drinking?

    1-23-45-67-910+

    Never

    Less Than Monthly

    Monthly

    Weekly

    Daily or almost daily

    How often do you have a drink containing alcohol?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often do you have six or more drinks on one occasion?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often during the last year have you found that you were not able to stop drinking once you had started?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often during the last year have you failed to do what was expected of you because of drinking?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often during the last year have you had a feeling of guilt or remorse after drinking?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    How often during the last year have you been unable to remember what happened the night before because of your drinking?

    NeverLess Than MonthlyMonthlyWeeklyDaily or Almost Daily

    No

    Yes, but not in the last year

    Yes, during the last year

    Have you or someone else been injured because of your drinking? Have you or someone else been injured because of your drinking?

    NoYes, but not in the last yearYes, during the last year

    Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

    NoYes, but not in the last yearYes, during the last year

    [prev "< Back"]
    [next "Next >"]

    [step_finish]
    [/group]

    [step_start "Alchohol Use"]

    Alchohol Use

    [progressbar type:numbers]

    Yes

    No

    Days Used

    Alchohol Use Example

    YesNo

    [prev "< Back"]
    [next "Next >"]

    [step_finish]

    [step_start "Drug Use"]

    Drug Use

    [progressbar type:numbers]

    Yes

    No

    Days Used

    Drug Use Example

    YesNo

    [prev "< Back"]
    [next "Next >"]

    [step_finish]

    [step_start "How you’re Feeling"]

    How you’re Feeling

    [progressbar type:numbers]

    Yes

    No

    Days Used

    How you’re Feeling Example

    YesNo



    [prev "< Back"]

    [step_finish]