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KETAMINE USAGE QUESTIONNAIRE
Thank you for helping us to research our forthcoming book about ketamine...
* please answer truthfully & feel free to leave out any questions that you are not comfortable with.
* feel free to include any extra information, opinions or anecdotal evidence that you feel will help us.
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Are you male or female?
Choose
Male
Female
How old are you?
Your answer
Where do you live? (City, County/State, Country please)
Your answer
How long have you been a ketamine user?
Your answer
Have you found that you have developed a tolerance with repeated use?
Choose
Yes
No
How long do you think that you will carry on using ketamine?
Your answer
How do you take it? (Snorting, i.v., i.m., orally, rectally)
Snorting/insufflation
I.V.
I.M.
Orally
Rectally
Clear selection
Do you use other drugs besides k?
Choose
Yes
No
How often do you take k & in what amounts?
(I.e. a few lines occasionally, a litre on a week-long bender, etc.)
Your answer
Do you feel that you have (or have ever had) a dependence on the substance?
Choose
Yes
No
What do you feel are the benefits of use?
Your answer
What do you think are the negative effects of use?
Your answer
Do you think that using k has affected your life overall a) positively, b) negatively or c) neutrally? Explanations welcome.
Your answer
Have you ever suffered any health problems arising from use, if so, what?
(e.g. “k cramps”, bladder problems, mood swings, psychosis, etc.)
Your answer
Where do you generally take k?
At home / friend's house
Club / rave / squat party
Outside
Other:
Clear selection
How much do you pay for ketamine (per gram, litre or vial please)?
Your answer
Do you feel that the laws in your country relating to k are fair & proportional?
Choose
Yes
No
Do you feel that public health services in your country are well informed & capable of dealing with issues relating to ketamine use?
Choose
Yes
No
Do you think that drug dependence agencies in your country are properly prepared for helping habitual ketamine users?
Choose
Yes
No
Do you think that the government in your country provides fair & accurate information about k?
Choose
Yes
No
Do you know what brands of ketamine you consume?
(please list if so)
Your answer
Do you know which country the ketamine that you consume originates from?
China
India
Mexico
Other:
Do you know what kind of drug ketamine is?
(e.g. dissociative, tranquiliser, hallucinogen, etc.).
Your answer
How many types of k are you aware of? Please list.
Your answer
Are you aware of the differences between the ketamine isomers (S+, S-, R+, and R-)?
Your answer
Are you aware that some brands of k also contain anti-cholinergics (& that these may add to the effects of the drug / be harmful to humans)?
Yes
No
Other:
Clear selection
Would you say that use of the drug has affected your belief system / view of reality? If so, in what way?
Your answer
How would you describe your experiences with k overall?
Your answer
Please list any slang names that you know for ketamine or k users.
Your answer
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