p>If substance checked in Question #17, please specify the TYPE(S), indicate the DATE(S) last used and NUMBER OF TIMES used: If substance checked in Question #17, please specify the TYPE(S), indicate the DATE(S) last used and NUMBER OF TIMES used:
I have tried, used, experimented, or in any way ingested into my body any of the following within the past five (5) years WITHOUT A PERSONAL DOCTORS PRESCRIPTION: ANABOLIC STERIODS: Synthetic tablet, capsule, liquid, cream, patch or injectable solution HALLUCINOGENS AND DISSOCIATIVE DRUGS: Ayahuasca, DMT, LSD, PCP, Psilocybin, Salvia INHALANTS: Solvents, Aerosols or Gases (Paint Thinner, Spray Paint, Glue, Markers, etc) OPIOIDS: Heroin, Codeine, Fentanyl, Hydrocodone, Dihydrocodeinone, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone, Thai Stick STIMULANTS: Amphetamine, Cocaine, Base Cocaine, Khat, Methamphetamine, Methylphenidate SYNTHETIC DRUGS: MDMA (Ecstasy or Mollies), Bath Salts (Synthetic Cathinones) N/A.
I have tried, used, experimented, or in any way ingested into my body any of the following within the past five (5) years WITHOUT A PERSONAL DOCTORS PRESCRIPTION: ANABOLIC STERIODS: Synthetic tablet, capsule, liquid, cream, patch or injectable solution HALLUCINOGENS AND DISSOCIATIVE DRUGS: Ayahuasca, DMT, LSD, PCP, Psilocybin, Salvia INHALANTS: Solvents, Aerosols or Gases (Paint Thinner, Spray Paint, Glue, Markers, etc) OPIOIDS: Heroin, Codeine, Fentanyl, Hydrocodone, Dihydrocodeinone, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone, Thai Stick STIMULANTS: Amphetamine, Cocaine, Base Cocaine, Khat, Methamphetamine, Methylphenidate SYNTHETIC DRUGS: MDMA (Ecstasy or Mollies), Bath Salts (Synthetic Cathinones) N/A.