TNAG-0690-FCO40-839-Review-of-narcotics-problem-in-Hong-Kong-1977 — Page 119

UNITED NATIONS

Division of Narcotic Drugs

1211 Geneva 10

Switzerland

NAME & ADDRESS OF SERVICE:

INDIVIDUAL DATA FORM ON DRUG ABUSE

Appendix &

FORM 1

5. Education: 1 Illiterate

2 Literate No. of years of education:

For each drug specified in Question 6, please answer Question 7 and, if

6. Please specify below within appropriate drug type*

all drugs which person has ever tried during his/her

lifetime, whether or not (s)he is currently using them

1. Name of Person:

►

2 Sex: 1 Masc.

2 Fem.

3. Age

4. Place of usual residence: 1 City 2 Small town

0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 & over

years and/or Date of Birth 3 Rural area

+

and/or Address:

and/or Ref. Number

"Yes" to Question 7, please answer Questions 8, 9 & 10 by inserting an X in the appropriate row and column below

was used?

10. Mode of use

7. Has this drug(s) been

used in last 12 months?

8. Was this the first

9. How often has drug(s) been used?

time the drug(s)

At least Weekly monthly but or more less than often

#

Less often

I than

Inhalation Injection

! Orally

| Other

No

Yes

No

| weekly

monthly

I

2

1

2

3

I

2

3

4

1

Yes

I

2N

1 1.1 Opium

1.2 Heroin

Opiate type

1.3

Other opiates, please specify

1.4

1.5

1.6 Synthetics, please specify

1.7

1.8

2 2.1

Cannabis type, please specify

2.2 2.3

3 3.1

Cocaine type, please specify

3.2

3.3

4 4.1

Hallucinogens, please specify

4.2

4.3

5.2

5.3

6 6.1

5 5.1 Amphetamine type, please specify.

Barbiturate type, please specify

6.2

6.3

7 7.1

7.2

Combination of drugs, please specify

7.3

8 8.1

Other, please specify

8.2

8.3

*See classification by drug type, page

6

}

}