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Personal Life Choices Survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Have you ever cheated in a relationship?
Select yes or no.
Yes
No
2
Rate your drug usage on a scale of 1 to 10
Rate your drug usage with 1 being the lowest and 10 being the highest.
3
Are you a drug user and crack smoker?
Provide a brief explanation.
4
Are you or have you ever been involved in prostitution?
Select yes or no.
Yes
No
5
Have you sought help or treatment for your drug usage?
Select yes or no.
Yes
No
6
Do you currently smoke crack?
Select yes or no.
Yes
No
7
How often do you use drugs?
Select the frequency that best represents your drug usage.
Rarely
Occasionally
Frequently
8
Do you consider your drug usage problematic?
Select yes or no.
Yes
No
9
What motivates you to engage in drug use?
Provide an open-ended response.
10
What are your intentions for seeking this survey?
Provide an open-ended response.
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