112 (112)    MH REPORT (601.93)

.| .| The Alcohol, Smoking and Substance Involvement Screening Test| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| 
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 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 
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>|  | ASSIST Scores:|    Tobacco: <-Tobacco->|    Alcohol: <-Alcohol->|    Cannabis: <-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 (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.)|     
Cocaine: <-Cocaine->|    Amphetamine: <-Amphetamine->|    Inhalants: <-Inhalants->|    Sedatives: <-Sedatives->|    Hallucingens: <-Hallucingens->|    Opioids: <-Opioids->|    Other: <-Other->| |    
<*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 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.|  $~
0-3   Low risk for health and other problems|    4-26  Moderate risk for health and other problems|    27+   High risk of experiencing severe problems and likely to be dependent. | | | 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, 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,