| RPT |
.| .| The Alcohol, Smoking and Substance Involvement Screening Test| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran:
PCP, Special K, etc.)| <*Answer_3958*>| 1i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_3960*>| 1j. Other| <*Answer_3961*>| Specify:| <*Answer_3964*>| |
2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)?| | 2a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)|
<*Answer_3965*>| 2b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3969*>| 2c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3970*>| 2d. Cocaine (coke, crack, etc.)|
<*Answer_3971*>| 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3988*>| 2f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3990*>|
2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3991*>| 2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_3992*>| 2i. Opioids (heroin,
morphine, methadone, codeine, etc.)| <*Answer_3993*>| 2j. Other (as specified previously)| <*Answer_3994*>| | 3. During the past three months, how often have you had a strong desire or
urge to use (FIRST DRUG, SECOND DRUG, ETC)?| | 3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3995*>| 3b. Alcoholic beverages (beer, wine, spirits, etc.)|
<*Answer_3996*>| 3c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3997*>| 3d. Cocaine (coke, crack, etc.)| <*Answer_3998*>| 3e. Amphetamine type stimulants (speed, diet pills,
ecstasy, etc.)| <*Answer_3999*>| 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4000*>| 3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|
<*Answer_4001*>| 3h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4002*>| 3i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4003*>| 3j. Other (as
<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | ASSIST Scores:| | Tobacco: <-Tobacco->| Alcohol:
specified previously)| <*Answer_4007*>| | 4. During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems?| | 4a.
Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4008*>| 4b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4009*>| 4c. Cannabis (marijuana, pot, grass,
hash, etc.)| <*Answer_4010*>| 4d. Cocaine (coke, crack, etc.)| <*Answer_4011*>| 4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4012*>| 4f. Inhalants
(nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4013*>| 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4014*>| 4h. Hallucinogens (LSD, acid, mushrooms,
PCP, Special K, etc.)| <*Answer_4017*>| 4i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4018*>| 4j. Other (as specified previously)| <*Answer_4020*>| | 5. During
the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)?| | 5a. Tobacco products| <*Answer_4021*>| 5b.
Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4023*>| 5c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4024*>| 5d. Cocaine (coke, crack, etc.)| <*Answer_4025*>|
5e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4026*>| 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4027*>| 5g. Sedatives or
Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4028*>| 5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4029*>| 5i. Opioids (heroin, morphine,
methadone, codeine, etc.)| <*Answer_4030*>| 5j. Other (as previous specified)| <*Answer_4031*>| | 6. Has a friend or relative or anyone else ever expressed concern about your use of
<-Alcohol->| Cannabis: <-Cannabis->| Cocaine: <-Cocaine->| Amphetamine: <-Amphetamine->| Inhalants: <-Inhalants->| Sedatives: <-Sedatives->| Hallucingens: <-Hallucingens->|
(FIRST DRUG, SECOND DRUG, ETC.)?| | 6a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4032*>| 6b. Alcoholic beverages (beer, wine, spirits, etc.)|
<*Answer_4034*>| 6c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4044*>| 6d. Cocaine (coke, crack, etc.)| <*Answer_4045*>| 6e. Amphetamine type stimulants (speed, diet pills,
ecstasy, etc.)| <*Answer_4046*>| 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4047*>| 6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|
<*Answer_4048*>| 6h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4049*>| 6i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4050*>| 6j. Other (as
previously specified)| <*Answer_4051*>| | 7. Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)?| | 7a. Tobacco products (cigarettes, chewing
tobacco, cigars, etc.)| <*Answer_4052*>| 7b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4053*>| 7c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4054*>| 7d.
Cocaine (coke, crack, etc.)| <*Answer_4055*>| 7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4086*>| 7f. Inhalants (nitrous, glue, petrol, paint thinner,
etc.)| <*Answer_4087*>| 7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4088*>| 7h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|
<*Answer_4089*>| 7i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4090*>| 7j. Other (as previously specified)| <*Answer_4189*>| | 8. Have you EVER used any drug by
injection? (Non-medical use only)| <*Answer_4237*>| 8a. What is your pattern of injecting?| <*Answer_4254*>| | | Information contained in this note is based on a self-report assessment
Opioids: <-Opioids->| Other: <-Other->| | For all scores except Alcohol:| 0-3 Low risk for health and other problems| 4-26 Moderate risk for health and other problems| 27+
and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
High risk for severe problems and likely to be addicted| | Alcohol score:| 0-10 Low risk for health and other problems| 11-26 Moderate risk for health and other problems| 27+ High
risk for severe problems and likely to be addicted| | | | Questions and Answers| | 1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)| | 1a. Tobacco
products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3934*>| 1b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3935*>| 1c. Cannabis (marijuana, pot, grass, hash,
etc.)| <*Answer_3936*>| 1d. Cocaine (coke, crack, etc.)| <*Answer_3937*>| 1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3945*>| 1f. Inhalants
(nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3956*>| 1g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3957*>| 1h. Hallucinogens (LSD, acid, mushrooms,
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