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*21w <br /> How often do you currently use street drugs? Never <br /> In a week <br /> In a month <br /> Per day <br /> What street drugs do you use? <br /> Vow often do you ingest caffeine? Never <br /> In a week <br /> In a month <br /> Per day <br /> Do you smoke? Yes No <br /> Have you ever sought help or been concerned about your nl ing or drug use? Yeses No <br /> If yes, describe what help you sought: ', <br /> { <br /> SEXUAL/PHYSICAL/EMOTIONAL ABUSE: <br /> Do you have any history of sexual abuse? Yes No <br /> i <br /> Have you ever been physically abused? Yes No <br /> Have you ever been emotionally abused? Yes No <br /> 4 <br />