Name
First Name
Last Name
Email
example@example.com
Input Table 1
Past Use
Current Use (within last month)
Alcohol
Cigarettes
Cannabis
Cocaine
Stimulants (meth)
Benzos (xanax)
Barbituates (Quaalude)
Heroin
Methadone
Buprenorphine
Opiates
LSD
PCP
Ecstasy (MDMA)
Mushrooms
Ketamine
Inhalants
Steroids
Prescription drugs
Input Table 2
Specify type or method of use
Use was experimental, infrequent, or regular
Age at first use
Age of heaviest use
Age of last use
#times used in last week
# times used in last 6 mo
Experienced dependence?
Experienced withdrawal?
Alcohol
Cigarettes
Cannabis
Cocaine
Stimulants (meth)
Benzos (xanax)
Barbituates (Quaalude)
Heroin
Methadone
Buprenorphine
Opiates
LSD
PCP
Ecstasy (MDMA)
Mushrooms
Ketamine
Inhalants
Steroids
Prescription drugs
Submit
Should be Empty: