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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.

Secured
1

Have you ever cheated in a relationship?

Select yes or 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.
5

Have you sought help or treatment for your drug usage?

Select yes or no.
6

Do you currently smoke crack?

Select yes or no.
7

How often do you use drugs?

Select the frequency that best represents your drug usage.
8

Do you consider your drug usage problematic?

Select yes or 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.