24 (24)    MH REPORT (601.93)

|.|.|Brief Addiction Monitor||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: 
did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)?  [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce can/bottle of beer or 5 ounce 
glass of wine.] |    <*Answer_5278*>|6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?|    <*Answer_5279*>|7. In the past 30 days, 
how many days did you use any of the following drugs: |  7A. Marijuana (cannabis, pot, weed)?|    <*Answer_5280*>|  7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, 
Phenobarbital, downers, etc.)?|    <*Answer_5281*>|  7C. Cocaine and/or Crack?|    <*Answer_5282*>|  7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal 
meth, ice, etc.)?|    <*Answer_5283*>|  7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2, 3, 4), Percocet, Vicodin, Fentanyl, etc.)?|    <*Answer_5284*>|  7F. 
Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?|    <*Answer_5285*>|  7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other 
over-the-counter or unknown medications)?|    <*Answer_5286*>|8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?|    <*Answer_5287*>|9. How 
confident are you that you will NOT use alcohol and drugs in the next 30 days?|    <*Answer_5288*>|10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support 
your recovery?|    <*Answer_5289*>|11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., 
around risky "people, places or things")?|    <*Answer_5290*>|12. Does your religion or spirituality help support your recovery?|    <*Answer_5291*>|13. In the past 30 days, how many days did you 
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Clinical Subscales|   Use: <-Use->|   Items 4, 5, 6. A high score indicates more use, range is 0 to 12. If a patient scores a 1 
spend much of the time at work, school, or doing volunteer work?|    <*Answer_5292*>|14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food 
and clothing for yourself and your dependents?|    <*Answer_5293*>|15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?| 
   <*Answer_5294*>|16. In the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?|    <*Answer_5295*>|17. How satisfied 
are you with your progress toward achieving your recovery goals?|    <*Answer_5296*>|||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 and procedures.|     |$~
or greater, it calls for further assessment and clinical attention, e.g., consider addition/change of pharmacotherapy or psychosocial intervention.   ||   Risk Factors: <-Risk Factors->|   Items 1, 
2, 3, 8, 11, 15. A high score indicates increased risk, range is 0 to 24. Clinicians are encouraged to consider scores on individual Risk items in offering interventions as indicated during initial 
treatment planning and following re-assessment.|   |   Protective Factors: <-Protective Factors->|   Items 9, 10, 12, 13, 14, 16. A high score indicates greater protective factors, range is 0 to 24. 
Clinicians are encouraged to consider scores on individual Protective items in offering interventions as indicated during initial treatment planning and following re-assessment.|||Questions and 
Answers||A. Date of administration:|    <*Answer_5272*>|B. Method of administration:|    <*Answer_5273*>|1. In the past 30 days, how would you say your physical health has been?|    
<*Answer_5274*>|2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?|    <*Answer_5275*>|3. In the past 30 days, how many days have you felt depressed, 
anxious, angry or very upset throughout most of the day?|    <*Answer_5276*>|4. In the past 30 days, how many days did you drink ANY alcohol?|    <*Answer_5277*>|5. In the past 30 days, how many days