The following questions are adapted from the Young Adult

University of the East Ramon Magsaysay Fertility Survey (version 4). Permission has been obtained to
Memorial Medical Center use them for this study.
COLLEGE OF MEDICINE Instructions: Please encircle your best answer. If some items
Aurora Boulevard, Quezon City are not applicable to you, please indicate N/A

This section is about SMOKING

We are a group of medical students from the University of the
East Ramon Magsaysay Memorial Medical Center, Inc. and 1. Have you ever tried smoking cigarettes?
we are conducting a research on young adult behaviors. Your a. Yes
participation in this survey is greatly appreciated. Please b. No
answer the following questions as truthfully, as completely
and as accurately as you can. Rest assured that all responses 2. At what age did you start smoking cigarettes?
will remain confidential and will be for research purposes _____________ (age in completed years)
only. If at any point, you feel uncomfortable with the
questions, you are free to discontinue participation. Thank 3. Why did you try smoking at that time (encircle all
you for your help! applicable)
a. Curiosity
The first five questions are about your demographic data. You b. Pressured by friends
may choose not to reveal certain data however questions c. Influenced by family members
with asterisks need to be answered d. Others: _____________________

Name: ____________________________________________ 4. Do you currently smoke?

Age: ______________________________________________ a. Yes
Contact Number: ____________________________________ b. No
Gender ____________________________________________
Educational attainment. Check only one which apply.* 5. At what age did you start smoking regularly?
o No schooling/elementary _____________ (Age in completed years)
o High school undergraduate
6. On the average how many sticks of cigarettes do you
o High School Graduate/vocational consume per day? ______________
o College or higher
7. Is your parent or guardian aware of your smoking
Do you have a permanent tattoo? * (Henna tattoo is not a a. Yes, both parents/guardians
permanent tattoo) b. Yes, father/male guardian only
o Yes c. Yes, mother/female guardian only
o No d. No
What age did you have your first tattoo* ? _________
Did you have the tattoo because you wanted it (and not 8. Do you want to stop smoking?
because you are forced, peer pressured or due to religious or a. Yes
tribal requirements*?) b. No
o Yes
o No 9. Have you ever tried to stop smoking
Are you part of a tribe or cult*? a. Yes
o Yes b. No
o No
10. Is there any family member currently smoking?
Do you want to have a copy of the results of the study? a. Yes
o Yes b. No
o No
How can we best reach you? 11. If yes, who are they? (encircle all applicable)
Email:______ _________________________ a. Father (1st guardian)
Cellphone Number:_____________________ b. Mother (2nd guardian)
Facebook URL:________________________ c. Brother
d. Sister
e. Others _______________________
f. N/A
 21. How many bottles or shot glasses do you consume
The following section is regarding DRINKING per drinking session? ( you may provide a rough
estimate)
12. Have you ever tried drinking? Beer
a. Yes Hard drinks
b. No Locally brewed spirits
Wine
13. At what age did you first try drinking? Mixed drinks
______________ (age in completed years) Others

14. Why did you try drinking that time? (encircle all 22. With whom do you usually drink?
applicable) a. Alone
a. Curiosity b. Barkada/friends
b. Pressured by friends c. Family/relatives
c. Influenced by family members d. Schoolmates
d. Others: _____________________ e. Sorority/fraternity mates
f. Others ______________
15. Recalling your first drinking session, who were your
first drinking partners 23. Why do you usually drink (may encircle all that
a. Barkada/friends apply)
b. Family/ relatives a. Enjoyment and relaxation
c. Sorority/fraternity mates b. To escape from problems and concerns
d. Schoolmates c. Pressure from others/can’t say no
e. Others: ___________________ d. Pakikisama
e. Nothing else to do
16. Do you currently drink? f. Others: ________________
a. Yes
b. No 24. Is your parent/guardian aware of your drinking?
a. Yes, both parents/guardians
17. How often do you drink? b. Yes, father/male guardian only
a. 5-7 times a week c. Yes, mother/female guardian only
b. 1-4 times a week d. No
c. 1-3 times a month
d. Occasionally 25. Have you gotten in trouble with connection to your
drinking?
18. At what age did you start drinking in question 17? a. Yes
____________ (age in completed years) b. No

19. When was the last time you drank? 26. In the past 12 months, did you get in trouble for your
a. Today, awhile ago drinking?
b. Yesterday a. Yes
c. In the past 7 days b. No
d. In the past 2-4 weeks
e. In the past month 27. Have you ever passed out in a drinking session
because you drank too much?
20. What kind of alcoholic beverage do you usually a. Yes
drink? (may encircle two) b. No
a. Beer
b. Hard drinks (i.e gin, cognac) 28. At what age did you first pass out in a drinking
c. Locally brewed spirits (i.e lambanog, basi) session? _____________ (Age in completed years)
d. Wine
e. Mixed drinks (i.e bloody mary, gin pomelo) 29. Do you want to stop drinking?
f. Others ____________ a. Yes
b. No

30. Have you ever stopped drinking?

a. Yes
b. No
 31. Is there any member of your family drinking c. 1-3 times a month
regularly? d. Occasionally
a. Yes
b. No 42. At what age did you start using drugs or substances
as per #41? ______________ (age In years)
32. Who are they? (encircle all that apply)
a. Father/ first person 43. What types of substances do you currently use?
b. Mother/second person (encircle all that apply)
c. Brother a. Cough syrup
d. Sister b. Rugby
e. Others_________ c. Marijuana
d. Shabu
The next set of questions are about DRUG USE e. Ecstasy
f. Sedative (Valium)
33. Have you ever tried drugs or other substances? g. Sleeping pill
a. Yes h. Others _______________
b. No
44. In what month and year have you last used drugs?
34. At what age did you first start using drugs or other Month : ______________
substances? ____________( age in completed years) Year: _________________

35. Why did you try using drugs that time? (encircle all
applicable)
a. Curiosity
b. Pressured by friends
c. Influenced by family members
d. Others: _____________________
45. Is your parent/guardian aware of your drug or
substance use?
a. Yes, both parents/guardians
b. Yes, father/male guardian only
c. Yes, mother/female guardian only
d. No

36. What types of drugs or substances have you taken 46. Have you ever gotten in trouble in connection with
(encircle all that apply) your drug/substance use?
a. Cough syrup a. Yes
b. Rugby b. No
c. Marijuana
d. Shabu 47. In the past 12 months, did you get in trouble in
e. Ecstasy connection with your drug/substance use?
f. Sedative (Valium) a. Yes
g. Sleeping pill b. No
h. Others _______________
48. Do you want to stop using drugs
37. Have you tried injecting drugs a. Yes
a. Yes b. No
b. No
49. Have you ever stopped using drugs?
38. Which drugs did you inject? (encircle all that apply) a. Yes
a. Heroin b. No
b. Cocaine
c. Anesthetic drug 50. If you answered YES for #49, why have you not
d. Others ______________ stopped using drugs? (encircle all that apply)
a. Enjoy/like using drugs
39. Have you shared needles with other drug users?
b. Pressure from friends
a. Yes
c. Temptation
b. No
d. Others ______________________
40. Are you currently using drugs or substances?
a. Yes 51. In case you decide to quit using substances, do you
b. No think you can quit any time?
a. Yes
41. How often do you use drugs or substances? b. No
a. 5-7 times a week
b. 1-4 times a week
 52. Have you ever been in a rehabilitation center in 62. Whom did you hit, slap, kick, or physically hurt in the
connection to your drug use problems? past 12 months?
a. Yes a. Mother
b. No b. Father
53. Is there any member of your using drugs c. Siblings
a. Yes d. 1st guardian
b. No e. 2nd guardian
f. Boyfriend/Girlfriend
54. If yes for #53, who are they? (encircle all that apply) g. Own children
a. Father/ first person h. Young children under guardian’s care
b. Mother/second person i. Friend
c. Brother j. Classmate/Schoolmate
d. Sister k. Teacher
e. Others_________ l. Schoolmate
The next set is about VIOLENCE m. Employer
55. Have you ever experienced being threatened by n. Others ______________________
someone?
a. Yes 63. Did you carry a weapon (such as a balisong, gun,
b. No knife, club, ice pick etc) in the past 12 months?
a. Yes
56. In the past 12 months, were you threatened by b. No
someone?
The next set of questions are about SUICIDE
a. Yes
64. Have you ever thought of committing suicide?
b. No
a. Yes
57. Have you ever experienced being hit, slapped, kicked b. No
or otherwise physically hurt by someone?
a. Yes 65. Have you tried to end your life/commit suicide?
b. No a. Yes
b. No
58. In the past 12 months, were you hit, slapped, or
otherwise physically hurt by someone? 66. At what age did you first attempt to commit suicide?
a. Yes _____________ (age in completed years)
b. No
59. Who hit, slapped, or physically hurt you? (encircle all 67. What methods did you use? (encircle all applicable)
applicable) a. Ingesting substances
a. Mother b. Slashed wrist
b. Father c. Hang self
c. Siblings d. Others_______________________
d. 1st guardian
e. 2nd guardian 68. Why did you attempt to commit suicide?
f. Boyfriend/Girlfriend a. Family problem
g. Own children b. Quarrel with BF/GF
h. Young children under guardian’s care c. Personal problem: _________________
i. Friend d. Others__________________________
j. Classmate/Schoolmate
k. Teacher 69. Has any of your family members or friends
l. Schoolmate attempted to commit suicide?
m. Employer a. Yes, family
n. Others ______________________ b. Yes, friends
60. Did you hit, slap, kick or physically hurt in the past 12 c. Yes, family and friends
months? d. No
a. Yes
b. No

61. Why did you hit, slap, kick, physically hurt in the past
12 months?
a. Yes
b. No