| RPT |
Brief Addiction Monitor - Consumption Items for CBT-SUD (BAM-C-CBT-SUD)
| Gender: <.Patient_Gender.>
|
|
| Days Alcohol Use: <-Days Alcohol Use->
| Days of Heavy Alcohol Use: <-Days Heavy Alcohol Use->
| Days Other Drug Use: <-Days Other Drug Use->
|
| Range is 0 to 30. If a patient scores a 1 or greater, it calls for
| further examination and clinical attention, e.g. consider addition of
| pharmacotherapy or higher level of care, add motivational interviewing.
|
|
| Questions and Answers
|
| A. Date of administration:
| <*Answer_9092*>
| B. Method of administration:
| <*Answer_9093*>
|
| 1. Since the last session, how many days did you drink ANY alcohol?
| <*Answer_9094*>
| Date Given: <.Date_Given.>
|
| 2. Since the last session, how many days 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_9095*>
|
| 3. Since the last session, how many days did you use any illegal or
| street drugs or abuse any prescription medications?
| <*Answer_9096*>
| Clinician: <.Staff_Ordered_By.>
|
| 4. Since the last session, how many days did you use any of the following
| drugs:
|
| 4A. Marijuana (cannabis, pot, weed)?
| <*Answer_9097*>
|
| 4B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan,
| Ambien, barbs, Phenobarbital, downers, etc.)?
| <*Answer_9098*>
| Location: <.Location.>
|
| 4C. Cocaine and/or Crack?
| <*Answer_9099*>
|
| 4D. Other Stimulants (e.g., amphetamine, methamphetamine, Dexedrine,
| Ritalin, Adderall, "speed", "crystal meth", "ice", etc.)?
| <*Answer_9100*>
|
| 4E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy,
| codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?
|
| <*Answer_9101*>
|
| 4F. Inhalants (glues, adhesives, nail polish remover, paint thinner,
| etc.)?
| <*Answer_9102*>
|
| 4G. Other drugs (steroids, non-prescription sleep and diet pills,
| Benadryl, Ephedra, other over-the-counter or unknown medications)?
| <*Answer_9103*>
|
| Veteran: <.Patient_Name_Last_First.>
|
| 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.
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
