185 (185)    MH REPORT (601.93)

|.|.|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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