| RPT |
|Clinical Impairment Assessment Questionnaire 3.0 (CIA)
| Gender: <.Patient_Gender.>
| <*Answer_7771*>
|
| Scores can range from 0 to 48 with a higher score being indicative of a
| higher level of psychosocial impairment secondary to eating disorder
| psychopathology. A score of 16 or greater may be used to predict eating
| disorder case status.
|
|
|Questions and Answers:
|
|
| 1 ... made it difficult to concentrate?
| <*Answer_8739*>
| 2 ... made you feel critical of yourself?
| <*Answer_8740*>
| 3 ... stopped you going out with others?
| <*Answer_8741*>
| 4 ... affected your work performance (if applicable)?
| <*Answer_8742*>
| 5 ... made you forgetful?
| Date Given: <.Date_Given.>
| <*Answer_8743*>
| 6 ... affected your ability to make everyday decisions?
| <*Answer_8744*>
| 7 ... interfered with meals with family or friends?
| <*Answer_8745*>
| 8 ... made you upset?
| <*Answer_8746*>
| 9 ... made you feel ashamed of yourself?
| <*Answer_8747*>
| 10 ... made it difficult to eat out with others?
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8748*>
| 11 ... made you feel guilty?
| <*Answer_8749*>
| 12 ... interfered with you doing things you used to enjoy?
| <*Answer_8750*>
| 13 ... made you absent-minded?
| <*Answer_8751*>
| 14 ... made you feel a failure?
| <*Answer_8752*>
| 15 ... interfered with your relationships with others?
| Location: <.Location.>
| <*Answer_8753*>
| 16 ... made you worry?
| <*Answer_8754*>
|
|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.
||Copyright Bohn and Fairburn, 2008
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
