ADOLESCENT USE OF MEDICATIONS QUESTIONNARE

AGE

GENDER

MALE

FEMALE

AREA OF RESIDENCE

WEST BEKAA

RASHAYA

MID BEKAA

NORTH BEKAA

AREA OF RESIDENCE

WEST BEKAA

RASHAYA

MID BEKAA

NORTH BEKAA

URBANICITY

VILLAGE

SMALL CITY

MEDIUM-SIZED CITY

LARGE CITY

WERE YOU AN IMMIGRANT OUTSIDE LEBANON?

YES

NO

APPROXIMATE FAMILY INCOME PER MONTH IN LEBANESE POUNDS

LESS THAN 1,000,000

1,000,000 - 2,000,000

2,000,000 - 3,000,000

3,000,000 - 4,000,000

MORE THAN 4,000,000

FATHER'S EMPLOYENT

EMPLOYED; PLEASE SPECIFY TYPE OF WORK:_____________________

UNEMPLOYED

RETIRED

FATHER'S EDUCATION

ELEMENTARY

INTERMEDIATE SCHOOL

HIGH SCHOOL

UNIVERSITY LEVEL EDUCATION

MOTHER'S EMPLOYMENT

EMPLOYED; PLEASE SPECIFY TYPE OF WORK:_______________________

UNEMPLOYED

RETIRED