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Withdrawal Survey
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1.
What is your gender?
(Required.)
Male
Female
Other (please specify)
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2.
Select the year range you were born in:
(Required.)
After 1997
1981–1997
1965–1980
1946–1964
Before 1946
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3.
Are you, or have you ever struggled with some form of withdrawal from a substance addiction?
(Required.)
Yes - Formerly Struggled with Withdrawal
Yes - Currently Struggling with Withdrawal
No - I Have Experienced Substance Addiction but Have Never Struggled with Withdrawal
No - I Have Never Experienced Substance Addiction or Struggled with Withdrawal