| RPT |
.|.|Illness Management and Recovery Scales (IMRS) - Client Self-Rating|
| Questions and Answers|
| 1. Progress towards personal goals: In the past 3 months, I have come up with.
| <*Answer_8335*>
| 2. Knowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication?
| <*Answer_8336*>
| 3. Involvement of family and friends in my mental health treatment: How much are family members, friends, boyfriend/girlfriend, and other people who are important to you (outside your mental health agency) involved in your mental health
treatment?
| <*Answer_8337*>
| 4. Contact with people outside of my family: In a normal week, how many times do you talk to someone outside of your family (like a friend, co-worker, classmate, roommate, etc.)
| <*Answer_8338*>
| Date Given: <.Date_Given.>
| 5. Time in structured roles: How much time do you spend working, volunteering, being a student, being a parent, taking care of someone else or someone else's house or apartment? That is, how much time do you spend in doing activities for or
with another person that are expected of you? (This would not include selfcare or personal home maintenance.)
| <*Answer_8339*>
| 6. Symptom distress: How much do your symptoms bother you?
| <*Answer_8340*>
| 7. Impairment of functioning: How much do your symptoms get in the way of you doing things that you would like to or need to do?
| <*Answer_8341*>
| 8. Relapse prevention planning: Which of the following would best describe what you know and what you have done in order not to have a relapse?
| <*Answer_8342*>
| 9. Relapse of symptoms: When is the last time you had a relapse of symptoms (that is, when your symptoms have gotten much worse)?
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8343*>
| 10. Psychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons?
| <*Answer_8344*>
| 11. Coping: How well do feel like you are coping with your mental or emotional illness from day to day?
| <*Answer_8345*>
| 12. Involvement with self-help activities: How involved are you in consumer run services, peer support groups, Alcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other similar self-help programs?
| <*Answer_8346*>
| 13. Using medication effectively: (Don't answer this question if your doctor has not prescribed medication for you). How often do you take your medication as prescribed?
| <*Answer_8347*>
| 14. Functioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, to difficulty showing up at appointments or paying attention during
| Location: <.Location.>|
them, or to increased symptoms. Over the past 3 months, how much did drinking get in the way of your functioning?
| <*Answer_8348*>
| 15. Functioning affected by drug use: Using street drugs, and misusing prescription or over-the-counter medication can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, to
difficulty showing up at appointments or paying attention during them, or to increased symptoms. Over the past 3 months, how much did drug use get in the way of your functioning?
| <*Answer_8349*>|||
|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.
| $~
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.>|
|<*Answer_999999999999*>|
|
