| RPT |
|.|.|SHORT INVENTORY OF PROBLEMS - AD (SIP-AD-START) |
Lifetime Total scores range from 0-15. Higher scores indicate more negative|
consequences associated with drinking or drug use across the lifetime.||
SIP-AD PAST 30-DAY TOTAL SCORE = <-30-DAY TOTAL SCORE->||
Subscale Scores:||
Physical = <-Physical->|
Interpersonal = <-Interpersonal->|
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
Intrapersonal = <-Intrapersonal->|
Impulse control = <-Impulse control->|
Social Responsibility = <-Social Responsibility->||
Past 30-day total scores range from 0-45. Higher scores indicate more negative|
consequences associated with drinking or drug use within the past 30 days.|
Subscale scores range from 0-9.||
Questions and Answers||
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
I have been unhappy because of my drinking or drug use.|
1a. Ever: <*Answer_8498*>|
1b. In the past 30 days: <*Answer_8499*>| |
Because of my drinking or drug use I have not eaten.|
2a. Ever: <*Answer_8500*>|
2b. In the past 30 days: <*Answer_8501*>| |
I have failed to do what was expected of me because of my drinking or drug use.|
3a. Ever: <*Answer_8502*>|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
3b. In the past 30 days: <*Answer_8503*>| |
I have felt guilty or ashamed because of my drinking or drug use.|
4a. Ever: <*Answer_8504*>|
4b. In the past 30 days: <*Answer_8505*>| |
I have taken foolish risks when I have been drinking or using drugs.|
5a. Ever: <*Answer_8506*>|
5b. In the past 30 days: <*Answer_8507*>| |
| Gender: <.Patient_Gender.>| |
When drinking or using drugs, I have done impulsive things that I regretted |
later.|
6a. Ever: <*Answer_8508*>|
6b. In the past 30 days: <*Answer_8509*>| |
I have been harmed by my drinking or drug use.|
7a. Ever: <*Answer_8510*>|
7b. In the past 30 days: <*Answer_8511*>| |
I have had money problems because of my drinking or drug use.|
8a. Ever: <*Answer_8512*>|
8b. In the past 30 days: <*Answer_8513*>| |
My physical appearance has been harmed by my drinking or drug use.|
9a. Ever: <*Answer_8514*>|
9b. In the past 30 days: <*Answer_8515*>| |
My family has been hurt by my drinking or drug use.|
10a. Ever: <*Answer_8516*>|
10b. In the past 30 days: <*Answer_8517*>| |
Session number: <*Answer_8528*> | |
A friendship or close relationship has been damaged by my drinking or drug use.|
11a. Ever: <*Answer_8518*>|
11b. In the past 30 days: <*Answer_8519*>| |
My drinking or drug use has gotten in the way of my growth as a person.|
12a. Ever: <*Answer_8520*>|
12b. In the past 30 days: <*Answer_8521*>||
My drinking or drug use has damaged my social life, popularity, and |
reputation.|
13a. Ever: <*Answer_8522*>|
13b. In the past 30 days: <*Answer_8523*>| |
I have spent too much or lost a lot of money because of my drinking or |
drug use.|
14a. Ever: <*Answer_8524*>|
14b. In the past 30 days: <*Answer_8525*>| |
I have had an accident while using or under the influence of alcohol or |
SIP-AD-LIFETIME TOTAL SCORE = <-LIFETIME SCORE->||
drugs.|
15a. Ever: <*Answer_8526*>|
15b. In the past 30 days: <*Answer_8527*>| |
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.| |
$~
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