25 (25)    MH REPORT (601.93)

.|.|Behavior and Symptom Identification Scale - Revised||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: 
<*Answer_3850*>|22. Did anyone talk to you about your drinking or drug use?|    <*Answer_3851*>|23. Did you try to hide your drinking or drug use?|    <*Answer_3852*>|24. Did you have problems from 
your drinking or drug use?|    <*Answer_3853*>|39. How old are you?|    <*Answer_3854*>|40. What is your sex?|    <*Answer_3855*>|41. Are you . . .|    <*Answer_3856*>|42. What is your race?|    
<*Answer_3857*>|43. What is your first language?|    <*Answer_3858*>|44. How much school have you completed?|    <*Answer_3859*>|45. Are you now. . .|    <*Answer_3860*>|46. Outside of your treatment 
providers, what is your main source of social support?|    <*Answer_3861*>|47. Where did you sleep in the past 30 days? (Check one or more)|    <*Answer_3862*>|Specify Other:|    <*Answer_3863*>|48. 
At any time in the past 30 days, did you work at a paying job?|    <*Answer_3864*>|49. At any time in the past 30 days, did you work at a volunteer job?|    <*Answer_3865*>|50. At any time in the 
past 30 days, were you a student in a high school, job training or college degree program?|    <*Answer_3866*>|51. Do you now receive disability benefits; for example, SSI, SSDI or other disability 
insurance? (Check one or more)|    <*Answer_3867*>|||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.|  $~
<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |Basis-R|   Depression and Functioning: <-Depression and Functioning->|   Interpersonal Problems: 
<-Interpersonal Problems->|   Psychotic Symptoms: <-Psychotic Symptoms->|   Alcohol/Drug Use: <-Alcohol/Drug Use->|   Emotional Lability: <-Emotional Lability->|   Self-Harm: <-Self-Harm->|   
Overall: <-Overall->||Questions and Answers||1. Managing your day-to-day life?|    <*Answer_3830*>|2. Coping with problems in your life?|    <*Answer_3831*>|3. Concentrating?|    <*Answer_3832*>|4. 
Get along with people in your family?|    <*Answer_3833*>|5. Get along with people outside your family?|    <*Answer_3834*>|6. Get along well in social situations?|    <*Answer_3835*>|7. Feel close 
to another person?|    <*Answer_3836*>|8. Feel like you had someone to turn to if you needed help?|    <*Answer_3837*>|9. Feel confident in yourself?|    <*Answer_3838*>|10. Feel sad or depressed?|   
 <*Answer_3839*>|11. Think about ending your life?|    <*Answer_3840*>|12. Feel nervous?|    <*Answer_3841*>|13. Have thoughts racing through your head?|    <*Answer_3842*>|14. Think you had special 
powers?|    <*Answer_3843*>|15. Hear voices or see things?|    <*Answer_3844*>|16. Think people were watching you?|    <*Answer_3845*>|17. Think people were against you?|    <*Answer_3846*>|18. Have 
mood swings?|    <*Answer_3847*>|19. Feel short-tempered?|    <*Answer_3848*>|20. Think about hurting yourself?|    <*Answer_3849*>|21. Did you have an urge to drink alcohol or take street drugs?|