| RPT |
.| .| Alcohol Smoking and Substance Involvement Screening - NIDA modified version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran:
Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)| <*Answer_6934*>| 1g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)|
<*Answer_6935*>| 1h. Street opioids (heroin, opium, etc.)| <*Answer_6936*>| 1i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine,
etc.)?| <*Answer_6937*>| 1j. Other| <*Answer_7174*>| Specify:| <*Answer_7175*>| 2a. In the past three months, how often have you used cannabis (marijuana, pot, grass, hash, etc.)?|
<*Answer_6939*>| 2b. In the past three months, how often have you used cocaine (coke, crack, etc.)?| <*Answer_6940*>| 2c. In the past three months, how often have you used prescription stimulants
(Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6941*>| 2d. In the past three months, how often have you used methamphetamine (speed, crystal meth, etc.)?| <*Answer_6942*>| 2e. In
the past three months, how often have you used inhalants (nitrous oxide, gas, paint thinner, etc.)?| <*Answer_6943*>| 2f. In the past three months, how often have you used sedatives or sleeping
pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?| <*Answer_6944*>| 2g. In the past three months, how often have you used hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?|
<*Answer_6945*>| 2h. In the past three months, how often have you used street opioids (heroin, opium, etc.)?| <*Answer_6946*>| 2i. In the past three months, how often have you used prescription
opioids (fentanyl, oxycodone, [OxyContin], hydrocodone [Vicodin],methadone, buprenorphine, etc.)?| <*Answer_6947*>| 2j. In the past three months, how often have you used other substances (as
specified above)?| <*Answer_7167*>| 3a. In the past 3 months, how often have you had a strong desire or urge to use cannabis (marijuana, pot, grass, hash, etc.)?| <*Answer_6949*>| 3b. In the
<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | ASSIST NIDA| Cannabis: <-Cannabis->|
past 3 months, how often have you had a strong desire or urge to use cocaine (coke, crack, etc.)?| <*Answer_6950*>| 3c. In the past 3 months, how often have you had a strong desire or urge to use
prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6951*>| 3d. In the past 3 months, how often have you had a strong desire or urge to use
methamphetamine (speed, crystal meth, etc.)?| <*Answer_6952*>| 3e. In the past 3 months, how often have you had a strong desire or urge to use inhalants (nitrous oxide, gas, paint thinner, etc.)?|
<*Answer_6953*>| 3f. In the past 3 months, how often have you had a strong desire or urge to use sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?|
<*Answer_6954*>| 3g. In the past 3 months, how often have you had a strong desire or urge to use hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| <*Answer_6955*>| 3h. In the past 3
months, how often have you had a strong desire or urge to use street Opioids (heroin, opium, etc.)?| <*Answer_6956*>| 3i. In the past 3 months, how often have you had a strong desire or urge to
use prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6957*>| 3j. In the past 3 months, how often have you had a strong desire
or urge to use other substances (as specified above)?| <*Answer_7169*>| 4a. During the past 3 months, how often has your use of cannabis (marijuana, pot, grass, hash, etc.) led to health, social,
legal or financial problems?| <*Answer_6959*>| 4b. During the past 3 months, how often has your use of cocaine (coke, crack, etc.) led to health, social, legal or financial problems?|
<*Answer_6960*>| 4c. During the past 3 months, how often has your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.) led to health, social, legal or
Cocaine: <-Cocaine->| Prescription stimulants: <-Prescription stimulants->| Methamphetamine: <-Methamphetamine->| Inhalants: <-Inhalants->| Sedatives or
financial problems?| <*Answer_6961*>| 4d. During the past 3 months, how often has your use of methamphetamine (speed, crystal meth, etc.) led to health, social, legal or financial problems?|
<*Answer_6962*>| 4e. During the past 3 months, how often has your use of inhalants (nitrous oxide, gas, paint thinner, etc.) led to health, social, legal or financial problems?| <*Answer_6963*>|
4f. During the past 3 months, how often has your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.) led to health, social, legal or financial problems?|
<*Answer_6964*>| 4g. During the past 3 months, how often has your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.) led to health, social, legal or financial problems?|
<*Answer_6965*>| 4h. During the past 3 months, how often has your use of street opioids (heroin, opium, etc.) led to health, social, legal or financial problems?| <*Answer_6966*>| 4i. During the
past 3 months, how often has your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.) led to health, social, legal or financial
problems? | <*Answer_6967*>| 4j. During the past 3 months, how often has your use of other substances (as specified above) led to health, social, legal or financial problems?|
<*Answer_7170*>| 5a. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of cannabis (marijuana, pot, grass, hash, etc.)?|
<*Answer_6969*>| 5b. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of cocaine (coke, crack, etc.)?| <*Answer_6970*>| 5c. During
the past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)? |
sleeping pills: <-Sedatives or sleeping pills->| Hallucinogens: <-Hallucinogens->| Street Opioids: <-Street Opioids->| Prescription opioids: <-Prescription opioids->|
<*Answer_6971*>| 5d. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of methamphetamine (speed, crystal meth etc.)?|
<*Answer_6972*>| 5e. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of inhalants (nitrous oxide, gas, paint thinner, etc.)?|
<*Answer_6973*>| 5f. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium,
Xanax, GHB, etc.)?| <*Answer_6974*>| 5g. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of hallucinogens ( LSD, acid, PCP, Special
K, ecstasy, etc.)?| <*Answer_7309*>| 5h. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of street Opioids (heroin, opium, etc.)?|
<*Answer_6976*>| 5i. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed opioids (fentanyl, oxycodone [OxyContin],
hydrocodone [Vicodin], methadone, buprenorphine, etc.)? | <*Answer_6977*>| 5j. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of
other substances (as specified above)?| <*Answer_7171*>| 6a. Has a friend or relative or anyone else ever expressed concern about your use of cannabis (marijuana, pot, grass, hash, etc.)?|
<*Answer_6979*>| 6b. Has a friend or relative or anyone else ever expressed concern about your use of cocaine (coke, crack, etc.)?| <*Answer_6980*>| 6c. Has a friend or relative or anyone else
ever expressed concern about your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6981*>| 6d. Has a friend or relative or anyone else ever
Other: <-Other->| | | Level of risk associated with different substance involvement score ranges| for illicit or nonmedical prescription drug use:|
expressed concern about your use of methamphetamine (speed, crystal meth, etc.)?| <*Answer_6982*>| 6e. Has a friend or relative or anyone else ever expressed concern about your use of inhalants
(nitrous oxide, gas, paint thinner, etc.)?| <*Answer_6983*>| 6f. Has a friend or relative or anyone else ever expressed concern about your use of sedatives or sleeping pills (Valium, Serepax,
Xanax, Ativan, Librium, GHB, etc.)?| <*Answer_6984*>| 6g. Has a friend or relative or anyone else ever expressed concern about your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?|
<*Answer_6985*>| 6h. Has a friend or relative or anyone else ever expressed concern about your use of street opioids (heroin, opium, etc.)?| <*Answer_6986*>| 6i. Has a friend or relative or
anyone else ever expressed concern about your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6987*>| 6j. Has a friend
or relative or anyone else ever expressed concern about your use of other substances (as specified above)?| <*Answer_7172*>| 7a. Have you ever tried and failed to control, cut down or stop using
cannabis (marijuana, pot, grass, hash, etc.)?| <*Answer_6989*>| 7b. Have you ever tried and failed to control, cut down or stop using cocaine (coke, crack, etc.)?| <*Answer_6990*>| 7c. Have
you ever tried and failed to control, cut down or stop using prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6991*>| 7d. Have you ever tried and
failed to control, cut down or stop using methamphetamine (speed, crystal meth, etc.)?| <*Answer_6992*>| 7e. Have you ever tried and failed to control, cut down or stop using inhalants (nitrous
oxide, gas, paint thinner, etc.)?| <*Answer_6993*>| 7f. Have you ever tried and failed to control, cut down or stop using sedatives or sleeping pills (Valium, Serepax, Xanax, Ativan, Librium, GHB,
0 - 3 Lower risk| 4 - 26 Moderate risk| 27+ High risk| | | Questions and Answers| | 1. Alcohol (for men, 5 or more drinks a day or for women, 4
etc.)?| <*Answer_6994*>| 7g. Have you ever tried and failed to control, cut down or stop using hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| <*Answer_6995*>| 7h. Have you ever
tried and failed to control, cut down or stop using street opioids (heroin, opium, etc.)?| <*Answer_6996*>| 7i. Have you ever tried and failed to control, cut down or stop using prescribed opioids
(fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6997*>| 7j. Have you ever tried and failed to control, cut down or stop using other substances
(as specified above)?| <*Answer_7173*>| 8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)?| <*Answer_6999*>| | | 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.| $~
or more drinks a day)| <*Answer_6925*>| 2. Tobacco Products| <*Answer_6926*>| 3. Prescription Drugs for Non-Medical Reasons| <*Answer_6927*>| 4. Illegal Drugs| <*Answer_6928*>| 1a.
Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_6929*>| 1b. Cocaine (coke, crack, etc.)| <*Answer_6930*>| 1c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet
pills, etc.)| <*Answer_6931*>| 1d. Methamphetamine (speed, crystal meth, ice, etc.)| <*Answer_6932*>| 1e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)| <*Answer_6933*>| 1f.
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