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Behaviour 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 cheated on your partner before?
Please select one option.
Yes
No
2
Rate your drug use on a scale of 1 to 10 (1 being the lowest and 10 the highest).
Please rate your drug use.
3
Do you engage in prostitution? No
Please provide your answer in the text box.
4
Do you use crack cocaine?
Please select one option.
Yes
No
5
Do you use heroin?
Please select one option.
Yes
No
6
Have you sought help for your drug use?
Please select one option.
Yes
No
7
Are you willing to seek help for your drug use?
Please select one option.
Yes
No
8
Are you currently in a relationship?
Please select one option.
Yes
No
9
Do you have any plans to quit the mentioned behaviors?
Please provide your answer in the text box.
10
Are you open to professional help and support?
Please select one option.
Yes
No
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