| RPT |
|.|.|SHORT INVENTORY OF PROBLEMS - AD (SIP-AD-30) |
Subscale Scores:||
Physical = <-Physical->|
Interpersonal = <-Interpersonal->|
Intrapersonal = <-Intrapersonal->|
Impulse control = <-Impulse control->|
Social Responsibility = <-Social Responsibility->||
Past 30-day total scores range from 0-45. Higher scores indicate more |
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
negative consequences associated with drinking or drug use within the |
past 30 days. Subscale scores range from 0-9.| |
Questions and Answers||
1. I have been unhappy because of my drinking or drug use.|
<*Answer_8483*>| |
2. Because of my drinking or drug use I have not eaten.|
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
<*Answer_8484*>| |
3. I have failed to do what was expected of me because of my drinking or |
drug use.|
<*Answer_8485*>| |
4. I have felt guilty or ashamed because of my drinking or drug use.|
<*Answer_8486*>| |
5. I have taken foolish risks when I have been drinking or using drugs.|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
<*Answer_8487*>| |
6. When drinking or using drugs, I have done impulsive things that I|
regretted later.|
<*Answer_8488*>| |
7. I have been harmed by my drinking or drug use.|
<*Answer_8489*>| |
8. I have had money problems because of my drinking or drug use.|
| Gender: <.Patient_Gender.>| |
<*Answer_8490*>| |
9. My physical appearance has been harmed by my drinking or drug use.|
<*Answer_8491*>| |
10. My family has been hurt by my drinking or drug use.|
<*Answer_8492*>| |
11. A friendship or close relationship has been damaged by my drinking or |
drug use.|
<*Answer_8493*>| |
12. My drinking or drug use has gotten in the way of my growth as a person.|
<*Answer_8494*>| |
13. My drinking or drug use has damaged my social life, popularity, and |
reputation.|
<*Answer_8495*>| |
14. I have spent too much or lost a lot of money because of my drinking or |
Session number: <*Answer_8529*>| |
drug use.|
<*Answer_8496*>| |
15. I have had an accident while using or under the influence of alcohol or |
drugs.|
<*Answer_8497*>||
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.| |
$~
SIP-AD PAST 30-DAY TOTAL SCORE = <-PAST 30 DAY TOTAL SCORE->||
|
