| Name___________________________________
Age_________ Sex________ Grade__________
1. Do you use drugs or alcohol? Yes____ No____
2. What drugs do you use?
____________________
____________________
____________________
2. Do you smoke? Yes____ No_____
3. How many cigarettes do you smoke?
___Over two packs
___1-packs
___Less than one pack
4. How old were you when you started smoking?
___14–16
___16–18
___18 or over
4. What percentage of the kids in your
high school use drugs or alcohol? ___
5. What percentage of the kids in your
high school smoke?_____________ |