Survey Form

Question 1

In the past month, have you slept comfortably?

• Never
• Rarely
• Occasionally
• Frequently
• Very often

Question 2

In the past month, have you had a need to drink or take drugs in the morning?

• Never
• Rarely
• Occasionally
• Frequently
• Very often

Question 3

In the past month, have you had withdrawal symptoms such as anxiety, dizziness, sweating