Older Adult Survey Question Title * 1. How old were you the first time consumed an alcoholic beverage? Under 18 years old 18-21 years old 21+ years old Don't Know Under 18 years old 18-21 years old 21+ years old Don't Know Question Title * 2. How frequently do you consume an alcoholic beverage? Daily Weekly Twice a Month Monthly Other Daily Weekly Twice a Month Monthly Other Other (please specify) Question Title * 3. On average, how many drinks do you consume in one sitting? 1-2 3-4 5-6 7+ 1-2 3-4 5-6 7+ Question Title * 4. Have you ever thought you might have a problem with alcohol? Yes No Don't know Yes No Don't know Question Title * 5. In the past 12 months, have you ever driven a motor vehicle within two hours after drinking an alcoholic beverage? Yes No Don't know Yes No Don't know Question Title * 6. Have you used the following substances more than five (5) times in your life? Yes No Take it as prescribed by a doctor? Barbiturates such as Phenobarbital (Meboral), Seconal, Luminol Barbiturates such as Phenobarbital (Meboral), Seconal, Luminol Yes Barbiturates such as Phenobarbital (Meboral), Seconal, Luminol No Barbiturates such as Phenobarbital (Meboral), Seconal, Luminol Take it as prescribed by a doctor? Tranquilizers such as Xanax or Valium Tranquilizers such as Xanax or Valium Yes Tranquilizers such as Xanax or Valium No Tranquilizers such as Xanax or Valium Take it as prescribed by a doctor? Sever pain-Vicodin Sever pain-Vicodin Yes Sever pain-Vicodin No Sever pain-Vicodin Take it as prescribed by a doctor? Pain suppressant such as Codeine, Demerol or other opiates Pain suppressant such as Codeine, Demerol or other opiates Yes Pain suppressant such as Codeine, Demerol or other opiates No Pain suppressant such as Codeine, Demerol or other opiates Take it as prescribed by a doctor? Oxycodone Oxycodone Yes Oxycodone No Oxycodone Take it as prescribed by a doctor? Methadone Methadone Yes Methadone No Methadone Take it as prescribed by a doctor? Question Title * 7. Have you ever used pain medication that was not prescribed to you? Yes No Yes No Question Title * 8. If yes, have you taken this pain medication within the past 30 days past 6 months past 12 months Other past 30 days past 6 months past 12 months Other Other (please specify) Question Title * 9. When taking your prescription medications, do you take the prescribed dosage? Yes No Sometimes Yes No Sometimes Question Title * 10. Do you read all of your prescription label warnings? Yes No Sometimes Yes No Sometimes Question Title * 11. Do you share medication with friends or family? Yes No Yes No Question Title * 12. Do you count your medication when you pick it up from the pharmacy? Yes No Yes No Question Title * 13. How many times in the last 30 days have you mixed prescription drugs with alcohol? Question Title * 14. During the past 12 months, have your driven a car after taking prescription medications that can impair your driving? Yes No Yes No Question Title * 15. Are you aware of the proper way to dispose of your unused prescribed medication? Yes No Yes No Question Title * 16. Services and information regarding substance abuse are readily available to older adults in Monmouth County. Agree Strongly Agree Disagree Strongly Disagree Agree Strongly Agree Disagree Strongly Disagree Question Title * 17. What year were you born? Question Title * 18. Gender Male Female Transgender Choose not to answer Male Female Transgender Choose not to answer Question Title * 19. Level of education Some High School High School Graduate Associate Degree Bachelor Degree Master Degree Doctorate Other Choose not to answer Some High School High School Graduate Associate Degree Bachelor Degree Master Degree Doctorate Other Choose not to answer Other (please specify) Question Title * 20. Marital Status Single Divorced Separated Widowed Civil Union Domestic Partnership Choose not to answer Single Divorced Separated Widowed Civil Union Domestic Partnership Choose not to answer Question Title * 21. Race/Ethnicity Caucasian Black/African American Latino/Hispanic Asian Native American Other Choose not to answer Caucasian Black/African American Latino/Hispanic Asian Native American Other Choose not to answer Other (please specify) Next
