| RPT |
.|.|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?|
|
