[step_start "About You"]

    About You

    [progressbar type:numbers]

    Have you drunk any alcohol in the last year?

    Please select yes or no.

    YesNo
    [next "Next >"]
    [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]