140 (140)    MH REPORT (601.93)

.|   .|   Short Inventory of Problems - 2L|   |   Date Given: <.Date_Given.>|   Clinician: <.Staff_Ordered_By.>|   Location: <.Location.>|   |   Veteran: <.Patient_Name_Last_First.>|   SSN: 
popularity, or reputation.|       <*Answer_7164*>|   14. I have spent too much or lost a lot of money because of my drinking.|       <*Answer_7165*>|   15. I have had an accident while drinking or 
intoxicated.|       <*Answer_7166*>|   |   |   |   All material appearing in this instrument is in the public domain and may be reproduced or copied without permission from the Institute or the 
authors. Citation of the source is appreciated.  NIH Publication No. 95-3911  Printed 1995|   |   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.|      $~
<.Patient_SSN.>|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|   Gender: <.Patient_Gender.>|   |   |                SIP-2L scale scores  |           |                      Physical: 
<-Physical->|                Inter-Personal: <-Inter-Personal->|                Intra-Personal: <-Intra-Personal->|               Impulse Control: <-Impulse Control->|         Social Responsibility: 
<-Social Responsibility->|           |                         Total: <-Total-> |   |   Questions and Answers|   |   1. I have been unhappy because of my drinking.|       <*Answer_7152*>|   2. 
Because of my drinking, I have not eaten properly.|       <*Answer_7153*>|   3. I have failed to do what is expected of me because of my drinking.|       <*Answer_7154*>|   4. I have felt guilty or 
ashamed because of my drinking.|       <*Answer_7155*>|   5. I have taken foolish risks when I have been drinking.|       <*Answer_7156*>|   6. When drinking, I have done impulsive things that I 
regretted later.|       <*Answer_7157*>|   7. My physical health has been harmed by my drinking.|       <*Answer_7158*>|   8. I have had money problems because of my drinking.|       <*Answer_7159*>| 
  9. My physical appearance has been harmed by my drinking.|       <*Answer_7160*>|   10. My family has been hurt by my drinking.|       <*Answer_7161*>|   11. A friendship or close relationship has 
been damaged by my drinking.|       <*Answer_7162*>|   12. My drinking has gotten in the way of my growth as a person.|       <*Answer_7163*>|   13. My drinking has damaged my social life,