□Did □3-6 not use times weekly □1-3 □Daily 3 times monthly □1-2 □Binge times weekly □Did □3-6 not use times weekly □1-3 □Daily 4 times monthly □1-2 □Binge times weekly Please indicate any substances used in the past 12 months (select all that apply): Substance Date Used Method of Use □Smoked □Injected Alcohol □Snorted □Swallowed □Smoked □Injected Amphetamines & other stimulants □Snorted □Swallowed □Smoked □Injected Barbiturates □Snorted □Swallowed □Smoked □Injected Benzodiazepines □Snorted □Swallowed □Smoked □Injected Cannabis □Snorted □Swallowed □Smoked □Injected Cocaine □Snorted □Swallowed □Smoked □Injected Crack □Snorted □Swallowed □Smoked □Injected Ecstasy/MDMA □Snorted □Swallowed □Smoked □Injected Glue/Inhalants
3 □Did not use □1-3 times monthly □1-2 times weekly □3-6 times weekly □Daily □Binge 4 □Did not use □1-3 times monthly □1-2 times weekly □3-6 times weekly □Daily □Binge Please indicate any substances used in the past 12 months (select all that apply): Substance Date Used Method of Use Alcohol □Smoked □Injected □Snorted □Swallowed Amphetamines & other stimulants □Smoked □Injected □Snorted □Swallowed Barbiturates □Smoked □Injected □Snorted □Swallowed Benzodiazepines □Smoked □Injected □Snorted □Swallowed Cannabis □Smoked □Injected □Snorted □Swallowed Cocaine □Smoked □Injected □Snorted □Swallowed Crack □Smoked □Injected □Snorted □Swallowed Ecstasy/MDMA □Smoked □Injected □Snorted □Swallowed Glue/Inhalants □Smoked □Injected