Research Questionaire - MethSolutions

Participant Code:*
This is provided in the email clicked to view this questionnaire
Your age
Your Gender
Age & Gender of other members of your family
Age Gender
How long have you lived at your home?
Do you own or rent the property?*
- Own
- Rent

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How much time do you and your family spend in your home?
Describe the type of activities you and your family undertake while at home (e.g. computer use, reading, cooking, active play, infants spending time on the floor)?
Do you regularly clean your home? Describe:
Have you undertaken renovations in your home at all? Describe:

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Have you or others in your home used amphetamine-type drugs?*
(Prescribed or Recreational)
- Yes
- No
If so, have you or others in your home used these drugs in your home?*
- Yes
- No
- N/A
If yes, please provide some additional information on which member of your family has used drugs (i.e. for how long, type of drugs)?
If these drugs were prescribed, what was the normal dose?

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Unusual dreams:*
- Yes
- No
If yes, please describe, and list individuals affected
Further description of health effects:
including severity and frequency (as relevant)

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Do you have any doctors reports or school records that support the health effects reported above?*
- Yes
- No

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Other comments and observations in relation to you or your family’s health, or concerns about health

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What levels of methamphetamine contamination has been found at your home?
File Upload
Please provide any tables of data and include any reports you have that provide this information. If you don't have digital copies, take a photo of the document(s) and upload this here. If you have more files to upload, please email them to research@methsolutions.co.nz

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Do you know if the contamination was from a drug lab (manufacture) or from drug use? – also indicate what you suspect from discussions you may have had with neighbours etc
Phone
This field is for validation purposes and should be left unchanged.

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Age	Gender