(PARTICIPANT INFORMATION)

Age: ___________

Gender: Male ( ) Female ( )

Marital Status: Married ( ) Single ( ) Divorced ( ) Separated ( ) Widow/Widower ( )

Number of children if any: _____________

Religious affiliation: Christian ( ) Muslim ( ) Traditional ( )

Ethnic Group: Igbo ( ) Hausa ( ) Yoruba ( ) others specify: ____________

Substance Abuse (11 items)

Instruction: The following questions concern information about your possible involvement

with drugs not including alcoholic beverages during the past 12 months. Carefully read each
statement and decide if your answer is "Yes" or "No". Then tick the appropriate response beside
the question.

S/N ITEMS YES NO

1. Have you used of over-the-counter drugs

2. Have you used drugs other than those required for medical reasons?

3. Do you abuse more than one drug at a time?

4. Are you unable to stop using drugs when you want to?

5. Have you ever had blackouts or flashbacks as a result of drug use?

6. Do you ever feel bad or guilty about your drug use?

7. Does your spouse (or parents) complain about your involvement

with drugs?
8. Have you neglected your family because of your use of drugs?

9. Have you engaged in illegal activities in order to obtain drugs?

10. Have you ever experienced withdrawal symptoms (felt sick) when
you stopped taking drugs?

11. Have you had medical problems as a result of your drug use (e.g..
memory loss, hepatitis, convulsions, bleeding)?