The following questions are about cocaine, including all the different forms such as powder, "crack", free base and coca paste. Cocaine is sometimes called coke or snow. 1. What are the names and local jargons given to this drug that you know? List them
2. How old were you when you first took the drug? _______
3. What /who influenced you to use this drug? (1) Social pressure (2) Parental example (3) Over work (4) Lack of a role in society (5) Mental illness (6) Shyness and fear (7) friends (8) Drug pushers (9) Nobody (10) Rebellion (11) Other _____________ 4. Have you taken these drugs in the past 12 months? (1) Yes (2) No
5. If Yes how many days in the past 1 month have you taken these drugs? a. None b. 1 - 2 days c. 3 - 5 days d. 6 - 9 days e. 10 - 19 days f. 20 or more days
6. If you have ever taken this drug, write the types used below:____________________ 7. In what ways have you taken this drug in the past 30 days?
a. Eating/Swallowing b. Injecting
c. Other
ways_________________________________________________________ 8. If ever injected, when was the most recent time you injected?
a. Today b. Yesterday c. In the past week d. In the past 30 days
e. More than 30 days and less than 12 months ago f. More than 12 months ago
9. Have you ever used a needle for injecting drugs when you knew or suspected that someone else had used the needle? (1) Yes (2) No
10. Has someone else ever-injected drugs with a needle after you used the needle? (1) Yes (2) No
11. How do you use the drug? (1) As an Individual (2) In a group (3) Both as an individual and in a group
12. How many tablets/injection have you had per day in the last 30 days?____________ 13. How much does it cost you? (1) Daily______ (2) Weekly______ (3)
14. Where do you get money to buy the drug? (1) Pocket money (2) Own income (3) Charities
(4) Other specify)_________________ 15. Where do you usually buy these drugs? (1) Pharmacy shops (2) Chemical shop (3)
Friends
(4) Other (specify) ____________________
16a. How do you buy it? (1) Myself (2) Someone (3) Both 1 & 2
16b.If someone, who? ___________________________________________ 16c.How old is the person? ______________
17. Under what circumstances do you take the drug?_____________________________ 18. What is your present state of health? (1) Good (2) Fairly good (3) Not so good
(4) Poor
19a. If not so good or poor, why do you think so?______________________________ 19b.What do you think is the cause?_________________________________________
Heroin
Answer these questions below if you have ever used Heroin.
The following questions are about heroin. Heroin is sometimes called brown sugar. This also makes the user feel ‘high’
1. What are the names and local jargons given to these drugs that you know? List them
Name Local jargon
3. What /who influenced you to take this drug? (1) Social pressure (2) Parental example (3) Over work (4) Lack of a role in society (5) Mental illness (6) Shyness and fear (7) Friends (8) Drug pushers (9) Nobody (10) Rebellion (11) Other ______________ 4. Have you taken this drug in the past 12 months? (1) Yes (2) No
5. If Yes how many days in the past 1 month have you taken this drug? a. None b. 1 - 2 days c. 3 - 5 days d. 6 - 9 days e. 10 - 19 days f. 20 or more days
6. If you have ever taken this drug, write the types used below:____________________ 7. In what ways have you taken this drug in the past 30 days?
a. Eating/Swallowing b. Injecting
c. Other
ways__________________________________________________________ 8. If ever injected, when was the most recent time you injected?
a. Today b. Yesterday c. In the past week d. In the past 30 days
e. More than 30 days and less than 12 months ago f. More than 12 months ago
9. Have you ever used a needle for injecting drugs when you knew or suspected that someone else had used the needle? (1) Yes (2) No
10. Has someone else ever-injected drugs with a needle after you used the needle? (1)Yes (2) No
11. How do you use the drug? (1) As an Individual (2) In a group (3) Both as an individual and in a group
12. How many tablets/injection have you had per day in the last 30 days?___________ 13. How much does it cost you? (1) Daily_____ (2) Weekly_____ (3) Monthly______ 14.Where do you get money to buy the drug? (1) Pocket money (2) Own income (3) Charities
15.Where do you usually buy the drug? (1) Pharmacy shops (2) Chemical shop (3) Friends
(4) Other (specify) _____________________ 16a How do you buy it? (1) Myself (2) Someone (3) Both 1 & 2
16b. If someone, who? ___________________________________________ 16c. How old is the person? ______________
17. Under what circumstances do you take the drug?_____________________________ 18. What is your present state of health? (1) Good (2) Fairly good (3) Not so good
(4) Poor
19a. If not so good or poor, why do you think so?________________________________ 19b. What do you think is the cause?_________________________________________
Opiates
Answer these questions below if you have ever used Opiates.
These are medicines containing opium, which are sometimes prescribed by doctors to relieve severe pain. Opium is a drug derived from dried poppy juice and used as a narcotic. Examples of opiates are codeine, morphine and pethidine.
1. What are the names and local jargons given to these drugs that you know? List them
Name Local jargon
2. How old were you when you first took the drug? _______
3. What /who influenced you to take these drugs? (1) Social pressure (2) Parental
example (3) Over work (4) Lack of a role in society (5) Mental illness (6) Shyness and fear (7) Friends (8) Drug pushers (9) Nobody (10) Rebellion (11) Other ____ 4. Have you taken these drugs in the past 12 months without a doctor's prescription? (1) Yes (2) No
5. If Yes how many days in the past 1 month have you taken these drugs without prescription? a. None b. 1 - 2 days c. 3 - 5 days d. 6 - 9 days e. 10 - 19 days f. 20 or more days
6. If you have ever taken these drugs, write the types used below:__________________ 7. In what ways have you taken these drugs in the past 30 days?
a. Eating/Swallowing b. Injecting
c. Other
ways_______________________________________________________ 8. If ever injected when was the most recent time you injected?
a. Today b. Yesterday c. In the past week d. In the past 30 days
e. More than 30 days and less than 12 months ago f. More than 12 months ago
9. Have you ever used a needle for injecting drugs when you knew or suspected that someone else had used the needle? (1)Yes (2) No
10. Has someone else ever injected drugs with a needle after you used the needle? (1) Yes (2) No
11. How do you use the drug? (1) As an Individual (2) In a group (3) Both as an individual and in a group
12. How many tablets/injection have you had per day in the last 30 days?_____________ 13. How much does it cost you? (1) Daily______ (2) Weekly____ (3) Monthly_______ 14. Where do you get money to buy the drug? (1) Pocket money (2) Own income (3)
Charities
(4) Other (specify)________________ 15. Where do you usually buy these drugs? (1) Pharmacy shops (2) Chemical shop (3) Friends
16a. How do you buy it? (1) Myself (2) Someone (3) Both 1 & 2
16b. If someone, who? ___________________________________________ 16c. How old is the person? ______________
17. Under what circumstances do you take the drug?____________________________ 18. What is your present state of health? (1) Good (2) Fairly good (3) Not so good
(4) Poor
19a. If not so good or poor, why do you think so?________________________________ 19b.What do you think is the cause?__________________________________________