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Have you experimented with Drugs?

Yes   No

Do you currently use Drugs?

Yes   No

Do you have pre-marital sex or promiscuous sex?

Yes   No

Do you Drink?

Yes   No

Do you Smoke?

Yes   No

Do you now or have you ever owned black clothing, especially concert tshirts?

Yes   No

Are you ever in a bad mood or fealt depressed?

Yes   No

Do you have problems with authority?

Yes   No

Have you had any problems with the Law?

Yes   No

Do you feel you need help at this time? (Not that it matters DRUGGIE you will GET STRAIGHT! We will see to it!)

Yes   No