I agree to be a subject in this study and I understand that:

My role as a subject is voluntary.

I may withdraw anytime without penalty.
All information obtained will be treated with the strictest confidence.
My name will not be used.
I will not be identifiable in any written reports about the study.

____________________
Signature


Type of school: Year level: Date:
Age: Sex: Weight (kilograms): Height (meters):


# QUESTIONS Yes No
Alcohol Use
1 I have never had a drink of alcohol other than a few sips.
2
I had my first drink of alcohol other than a few sips at or before age
13.

3 During the past 30 days, I drank atleast 1 drink containing alcohol.
4
During the past 30 days, I drank atleast 1 drink containing alcohol in
three or more separate days.

5
During the past 30 days, I drank 2 or more drinks per day on the days
that I drank alcohol.

6
During the past 30 days, how did you usually get the alcohol you
drank? (SELECT ONLY ONE RESPONSE)

a. I do not drink alcohol
b. I bought it in a store, shop, or from a street vendor
c. I gave someone else money to buy it for me
d. I got it from my friends
e. I got it from my family
f. I stole it or got it without permission
g. I got it some other way

Staggering when walking, not being able to speak right, and
throwing up are some signs of being really drunk.

7 I have been drunk atleast once in my life.
8 I drank so much alcohol that I got drunk at or before age 13.

9
During your life, how many times did you drink so much alcohol that
you were really drunk?
a. 0 times
b. 3 to 9 times
c. 10 or more times
10
During the past 30 days, I got into trouble with my family or friends,
missed school, or got into fights as a result of drinking alcohol.

Dietary Behavior
1
During the past 30 days, I get hungry most of the time because there
was not enough food at home,

2 During the past 30 days, I did not eat fruits
3 During the past 30 days, I usually ate fruits one or more times per day
4 During the past 30 days, I did not eat vegetables
5
During the past 30 days, I usually ate vegetables one or more times
per day

6
During the past 30 days, I usually drank carbonated soft drinks up to
two or more times/day

7 During the past 7 days, I ate or ordered from a fast-food restaurant
Physical Activity
1
I have been physically active all seven days for a total of at least 60
minutes per day during the past seven days.

2
During a typical or usual week, I am physically active seven days for a
total of at least 60 minutes per day.

3
I went to physical education class 4 or more days each week during
this school year.

4
I spend three or more hours per day during a typical day sitting and
watching television or doing sitting activities such as reading a novel.

Tobacco Use
1
How old were you when you first tried a cigarette?
a. I have never smoked a cigarette
b. 9 years or younger
c. 10 years or older
2 I smoked cigarettes on one or more days during the past 30 days.
3
I have used other forms of tobacco, such as tobacco roll, snuff, or
chew tobacco on one or more days during the past 30 days
4
During the past 12 months, have you ever tried to stop smoking
cigarettes?

a. I have never smoked a cigarette
b. Yes
c. No
5
One or both of my parents / guardians smoke cigarettes or use any
form of tobacco