| Question | Yes | No |
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| 1. Have you ever kissed someone? | | |
| 2. Have you ever made out with someone? | | |
| 3. Have you ever had sex with someone? | | |
| 4. Have you ever drank alcohol? | | |
| 5. Have you ever gotten drunk? | | |
| 6. Have you ever gotten such a bad hangover you threw up because of it? | | |
| 7. Have you ever consumed marijuana in any way? (brownies, tea, joints, etc.) | | |
| 8. Have you ever gotten so high that you thought you were someone different than you actually are? | | |
| 9. Have you ever gotten so high that you woke up not knowing how you got there? | | |
| 10. Have you ever smoked cigarettes? | | |
| 11. Have you ever done any other type of hallucinogen such as LSD, microdots, ecstasy, mushrooms, etc.? | | |
| 12. Have you ever done other sorts of stimulants such as crack cocaine, cocaine, methamphetamine, etc.? | | |
| 13. Have you ever dumped someone because you wanted to see someone else? | | |
| 14. Have you ever cheated on someone? | | |
| 15. Have you ever been abused? | | |
| 16. Have you ever hated someone and still not forgiven them? | | |
| 17. Have you ever gotten into a physical fight with someone? | | |
| 18. Have you ever been abused? | | |
| 19. Have you ever broken a romantic couple up because you were jealous? | | |
| 20. Do you think you're pure? | | |
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