DRUG CATEGORY (circle each substance used) |
Age when you first used this: |
How much & how often did you use this? |
How many years did you use this? |
When did you last use this? |
Do you currentlyuse this? |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |
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YesNo |