SOCIO-DEMOGRAPHIC DATA

1. Name
2. Address & Mob. No.

3. Age
4. Gender (Put a tick mark) Male Female
5. Education
6. Social Group (Put a tick mark) General SC ST OBC Other
7. Community (Put a tick mark) Nepali Bhutia Lepcha Other
8. Religion (Put a tick mark) Hindu Muslim Buddhis Christian Other
t
9. Occupation
10. Income (P/M)
11. Marital Status (Put a tick mark) Single Married Divorced
12. Duration of Substance
Dependence
13. Type of substance used at
present
14. Quantity per day

15. Any psychiatric illness

16. Any family history of psychiatric

illness
17. Any suicide attempts
18. Any family history of suicide
ABOUT FAMILY
Sl. No. Relation with Sex Marital Age Education Occupation Income
respondent Status (per
month)
1.
2.
3.
4.
5.
6.