Name *

First

Last

Email *

1) Do you feel that you need a cigarette, drug or alcohol in order to function? *

• Yes
• No
• Sometimes
• Always

2) Do you feel that you need a lot of tea/coffee to go by your day and energy? *

• Yes
• No
• Sometimes
• Always

3) Do you feel that you need to check your mobile phones every time? *

• Yes
• No
• Sometimes
• Always

4) Can you live a day without WhatsApp, Facebook or any kind of social media or calls? *

• Yes
• No
• Sometimes
• Always

5) Have you ever lied about your use of drugs, cigarette alcohol? *

• Yes
• No
• Sometimes
• Always

6) How many social media sites you have accounts with? *

• Yes
• No
• Sometimes
• Always

7) How many times a day do you look at social media? *

• Yes
• No
• Sometimes
• Always

8) How much time do you spend on social media per day? *

• Yes
• No
• Sometimes
• Always

9) How often do you post on social media? *

• Yes
• No
• Sometimes
• Always

10) When do you access social media? *

• Yes
• No
• Sometimes
• Always

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