June 2013: Altered States

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June 2013: Altered States

Alcohol and drug abuse can create physical and psychological problems for people living with HIV, and for others it can lead to unintentional exposure to the virus. Please take our confidential survey and let POZ know what role alcohol and/or drugs play in your life.
 
1. How often do you currently drink alcohol?
Never (skip to question 8)
Sometimes (a few times a month)
Often (a few times a week)
Daily
 
2. Have you ever felt bad or guilty about your drinking?
Yes
No
 
3. Have you ever felt you should cut down on your drinking?
Yes
No
 
4. Have your friends or family ever encouraged you to cut down on your drinking?
Yes
No
 
5. Have you ever tried to cut down on your drinking?
Yes
No
 
6. Have you ever gone to counseling or rehab because of your drinking?
Yes
No
 
7. Have you ever missed or skipped a dose of your HIV medication because of your drinking?
Yes
No
 
8. Do you use any of the following recreational drugs?
Cocaine
Crystal meth
Ecstasy
Heroin
Marijuana
Other
I do not use recreational drugs (skip to question 16)
 
9. How often do you currently use recreational drugs?
Rarely (a few times a year)
Sometimes (a few times a month)
Often (a few times a week)
Daily
 
10. Have you ever felt bad or guilty about your drug use?
Yes
No
 
11. Have you ever felt you should cut down on your drug use?
Yes
No
 
12. Have your friends or family ever encouraged you to cut down on your drug use?
Yes
No
 
13. Have you ever tried to cut down on your drug use?
Yes
No
 
14. Have you ever gone to counseling or rehab because of your drug use?
Yes
No
 
15. Have you ever missed or skipped a dose of your HIV medication because of your drug use?
Yes
No
 
16. What year were you born?
 
17. What is your gender?
Male
Female
Transgender
Other
 
18. What is your sexual orientation?
Straight
Gay/Lesbian
Bisexual
Other
 
19. What is your ethnicity? (Check all that apply.)
American Indian or Alaska Native
Arab or Middle Eastern
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
(please specify): 
 
20. What is your zip code?



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