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Please answer the following questions regarding your tobacco, alcohol and drug habits.





Altogether, have you smoked at least 100 or more cigarettes in your entire lifetime?





How long have you smoked (cumulatively)?





Prior to the onset of the Corona/COVID-19 crisis in your area, did you smoke cigarettes every day, some days or not at all?





Prior to the onset of the Corona/COVID-19 crisis in your area, on average, how many cigarettes did you smoke a day (1 pack = 20 cigarettes)?





Prior to the onset of the Corona/COVID-19 crisis in your area, how soon after you wake up did you smoke your first cigarette?





In the 30 days prior to the onset of the Corona/COVID-19 crisis in your area, what tobacco products OTHER THAN cigarettes have you used (check all that apply)?




Prior to the onset of the Corona/COVID-19 crisis in your area, how often did you have a drink containing alcohol?





Prior to the onset of the Corona/COVID-19 crisis in your area, how many drinks containing alcohol did have on a typical day when you are drinking?





Prior to the onset of the Corona/COVID-19 crisis in your area, how often did you have six or more drinks on one occasion?





How often during the last year prior to the onset of the Corona/COVID-19 crisis in your area have you found that you were not able to stop drinking once you had started?





How often during the last year prior to the onset of the Corona/COVID-19 crisis in your area have you failed to do what was normally expected from you because of drinking?





How often during the last year prior to the onset of the Corona/COVID-19 crisis in your area have you needed a first drink in the morning to get yourself going after a heavy drinking session?





How often during the last year prior to the onset of the Corona/COVID-19 crisis in your area have you had a feeling of guilt or remorse after drinking?





How often during the last year prior to the onset of the Corona/COVID-19 crisis in your area have you been unable to remember what happened the night before because you had been drinking?





Prior to the onset of the Corona/COVID-19 crisis in your area, have you or someone else been injured as a result of your drinking?





Prior to the onset of the Corona/COVID-19 crisis in your area, has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?





Have you used any cannabis over the 6 months prior to the onset of the Corona/COVID-19 crisis in your area ?





If yes...




How often do you use cannabis?





How many hours were you ‘stoned’ on a typical day when you had been using Cannabis?





How often during the six months prior to the onset of the Corona/COVID-19 crisis in your area did you find that you were not able to stop using cannabis once you had started?





How often during the six months prior to the onset of the Corona/COVID-19 crisis in your area did you fail to do what was normally expected from you because of using cannabis?





How often in the six months prior to the onset of the Corona/COVID-19 crisis in your area have you devoted a great deal of your time to getting, using, or recovering from cannabis?





How often in the six months prior to the onset of the Corona/COVID-19 crisis in your area have you had a problem with your memory or concentration after using cannabis?





How often do you use cannabis in situations that could be physically hazardous, such as driving, operating machinery, or caring for children?





Have you ever thought about cutting down, or stopping, your use of cannabis?





Below is a list of questions concerning information about your potential involvement with drugs, excluding alcohol, marijuana and tobacco, during the 12 months prior to the onset of the Corona/COVID-19 crisis in your area.

When the words “drug abuse” are used, they mean the use of prescribed or over‐the‐counter medications/drugs in excess of the directions and any non‐medical use of drugs. The various classes of drugs may include: solvents, tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin).

Remember that the questions do not include alcohol, marijuana or tobacco.




Prior to the onset of the Corona/COVID-19 crisis in your area, have you used drugs other than those required for medical reasons?





Prior to the onset of the Corona/COVID-19 crisis in your area, do you abuse more than one drug at a time?





Prior to the onset of the Corona/COVID-19 crisis in your area, are you always able to stop using drugs when you want to? (If never use drugs, answer “Yes.” )





Prior to the onset of the Corona/COVID-19 crisis in your area, have you had "blackouts" or "flashbacks" as a result of drug use?





Prior to the onset of the Corona/COVID-19 crisis in your area, do you ever feel bad or guilty about your drug use? If never use drugs, choose “No.”





Prior to the onset of the Corona/COVID-19 crisis in your area, does your spouse (or parents) ever complain about your involvement with drugs?





Prior to the onset of the Corona/COVID-19 crisis in your area, have you neglected your family because of your use of drugs?





Prior to the onset of the Corona/COVID-19 crisis in your area, have you engaged in illegal activities in order to obtain drugs?





Prior to the onset of the Corona/COVID-19 crisis in your area, have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?





Prior to the onset of the Corona/COVID-19 crisis in your area, have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?





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