Name	Value
REPORT NUMBER	147
INSTRUMENT	CSI-4
RPT	.\| .\| Couple Satisfaction Index-4\| \| Date Given: <.Date_Given.>\| Clinician: <.Staff_Ordered_By.>\| Location: <.Location.>\| \| Veteran: <.Patient_Name_Last_First.>\| SSN: <.Patient_SSN.>\| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\| Gender: <.Patient_Gender.>\| \| \| \| CSI-4 Score: <-CSI-4->\| \| \| Questions and Answers\| \| 1. Please indicate the degree of happiness, all things considered, of your relationship.\| <Answer_6484>\| 2. I have a warm and comfortable relationship with my partner.\| <Answer_6488>\| 3. How rewarding is your relationship with your partner?\| <Answer_6492>\| 4. In general, how satisfied are you with your relationship?\| <Answer_6559>\| \| \| 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.\| $~

Name

Value

REPORT NUMBER

147

INSTRUMENT

RPT

.| .| Couple Satisfaction Index-4| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |   CSI-4 Score: <-CSI-4->| | | Questions and Answers| | 1. Please indicate the degree of happiness, all things considered,
 of your relationship.|     <*Answer_6484*>| 2. I have a warm and comfortable relationship with my partner.|     <*Answer_6488*>| 3. How rewarding is your relationship with your partner?|
     <*Answer_6492*>| 4. In general, how satisfied are you with your relationship?|     <*Answer_6559*>|
| | 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.|  $~

147 (147) MH REPORT (601.93)