| RPT |
|Moral Injury Outcome Scale (MIOS+B-IPF)
| Gender: <.Patient_Gender.>
|
|<*Answer_7771*>
|
|
|Questions and Answers:
|
| Have you had at least one experience like this that troubles you
| currently?
| <*Answer_8922*>
|
| If yes, please check the type of experience that is most currently
| distressing. If more than one, check all that apply.
<*Answer_7772*>
|
|
| MIOS
|
| 1. I blame myself.
| <*Answer_8924*>
| 2. I have lost faith in humanity.
| Date Given: <.Date_Given.>
| <*Answer_8925*>
| 3. People would hate me if they really knew me.
| <*Answer_8926*>
| 4. I have trouble seeing goodness in others.
| <*Answer_8927*>
| 5. People don't deserve second chances.
| <*Answer_8928*>
| 6. I am disgusted by what happened.
| <*Answer_8929*>
| 7. I feel like I don't deserve a good life.
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8930*>
| 8. I keep myself from having success.
| <*Answer_8931*>
| 9. I no longer believe there is a higher power.
| <*Answer_8932*>
| 10. I lost trust in others.
| <*Answer_8933*>
| 11. I am angry all the time.
| <*Answer_8934*>
| 12. I am not the good person I thought I was.
| Location: <.Location.>
| <*Answer_8935*>
| 13. I have lost pride in myself.
| <*Answer_8936*>
| 14. I cannot be honest with other people.
| <*Answer_8937*>
|
| B-IPF
|
| 1. Romantic relationships with spouse or partner
| <*Answer_8938*>
|
| 2. Relationships with your children
| <*Answer_8939*>
| 3. Relationships with other family members
| <*Answer_8940*>
| 4. Friendships or socializing
| <*Answer_8941*>
| 5. Professional (work, education, training)
| <*Answer_8942*>
| 6. Hobbies and recreation activities that you do alone
| <*Answer_8943*>
| Veteran: <.Patient_Name_Last_First.>
| 7. Hobbies and recreation activities that you do with others
| <*Answer_8944*>
| 8. Religious faith/spirituality
| <*Answer_8945*>
| 9. Day to day activities, such as chores, errands, finances, health
| <*Answer_8946*>
|
|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
| SSN: <.Patient_SSN.>
|other diagnostic activities.
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
