In the last 12 months have you used alcohol or other drugs?

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* 1. In the last 12 months have you used alcohol or other drugs?

If yes, which substances have you used?

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* 2. If yes, which substances have you used?

Alcohol

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* 3. Alcohol

Cannabis

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* 4. Cannabis

Tobacco

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* 5. Tobacco

Crystal Methamphetamine (Ice)

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* 6. Crystal Methamphetamine (Ice)

Heroin/Opium/Poppy products

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* 7. Heroin/Opium/Poppy products

Ecstasy/MDMA

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* 8. Ecstasy/MDMA

Speed

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* 9. Speed

Energy drinks

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* 10. Energy drinks

Valium

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* 11. Valium

Codeine

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* 12. Codeine

Benzodiazepine

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* 13. Benzodiazepine

Rohypnol

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* 14. Rohypnol

OxyContin

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* 15. OxyContin

Pseudoephedrine

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* 16. Pseudoephedrine

Happy herb products

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* 17. Happy herb products

Steroids

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* 18. Steroids

Methadone/Suboxone/Subutex

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* 19. Methadone/Suboxone/Subutex

Mushrooms

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* 20. Mushrooms

Amyl Nitrate

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* 21. Amyl Nitrate

Other pharmaceuticals

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* 22. Other pharmaceuticals

Your Postcode?

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* 23. Your Postcode?

What is your preferred method of use?

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* 24. What is your preferred method of use?

Have you had any negative effects as a result of your use?

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* 25. Have you had any negative effects as a result of your use?

If yes, please circle or tick as many as applicable

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* 26. If yes, please circle or tick as many as applicable

Have you had any positive effects from your use?

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* 27. Have you had any positive effects from your use?

If yes, please tick as many as applicable 

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* 28. If yes, please tick as many as applicable 

Are there any alcohol or drug issues in the Huon Valley that you would like to see addressed?

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* 29. Are there any alcohol or drug issues in the Huon Valley that you would like to see addressed?

How should it be addressed? Tick as many as applicable.

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* 30. How should it be addressed? Tick as many as applicable.

Your Age?

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* 31. Your Age?

Your gender?

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* 32. Your gender?

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