S. No.

QUESTION.

ANSWER.

1.

Do you take any alcoholic beverage?

[1] Yes

[2] No

2.

If yes, please specify:

3.

Do you take alcohol:

[1] Yes

[2] No

4.

If yes, which type of alcohol/s do you take?

5.

If yes, how many standard drinks do you take in one drinking session?

6.

If yes, For how long have you take alcohol?

7.

Do you smoke cigarettes?

[1] Yes

[2] No

8.

If yes, how many cigarettes do you take in one day?

9.

If yes, how long have you taken cigarette?

10.

Do you take any other type of drug?

[1] Yes

[2] No

11.

If yes, please specify: