| RPT |
| Brief Addiction Monitor - Revised for CSG-SUD (BAM-R-CSG-SUD)
| Gender: <.Patient_Gender.>
|
| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine
| (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?
| <*Answer_9122*>
|
| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?
| <*Answer_9123*>
|
| 7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl,
| Ephedra, other over-the-counter or unknown medications)?
|
| <*Answer_9124*>
|
| 8. In the past 30 days, how much were you bothered by cravings or urges to
| drink alcohol or use drugs?
| <*Answer_9107*>
|
| 9. How confident are you that you will NOT use alcohol and drugs in the
| next 30 days?
| <*Answer_9108*>
|
|
| 10. In the past 30 days, how many days did you attend self-help meetings like
| AA or NA to support your recovery?
| <*Answer_9125*>
|
| 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_9126*>
|
| 12. Does your religion or spirituality help support your recovery?
|Clinical Subscales
| <*Answer_9109*>
|
| 13. In the past 30 days, how many days did you spend much of the time at
| work, school, or doing volunteer work?
| <*Answer_9127*>
|
| 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_9110*>
|
|
| 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_9111*>
|
| 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_9128*>
|
| 17. How satisfied are you with your progress toward achieving your recovery
| Use: <-Use->
| goals?
| <*Answer_9112*>
|
|
| 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.
| Items 4, 5A, 6. A high score indicates more use, range is 0 to 90. If a
| patient scores a 1 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 180. For subscale scores, items with ordinal response options (0-4) were
| converted to contribute proportionately consistent with items on days of
| use (0-30). 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->
| Date Given: <.Date_Given.>
| Items 9, 10, 12, 13, 14, 16. A high score indicates greater protective
| factors, range is 0 to 180. For subscale scores, items with ordinal
| response options (0-4) were converted to contribute proportionately
| consistent with items on days of use (0-30). Clinicians are encouraged
| to consider scores on individual Protective items in offering interventions
| as indicated during initial treatment planning and following re-assessment.
|
| Average Drinks (5B): <*Answer_9129*>
| Highest Consumed (5C): <*Answer_9130*>
| Items 5B and 5C should be reviewed and interpreted at the item-level and
| Clinician: <.Staff_Ordered_By.>
| are not included in any composite scores. These items provide additional,
| clinically useful information about quantity of alcohol use that users are
| encouraged to review and monitor, in addition to the frequency of use, risk
| and protective composite scores, to inform treatment planning and treatment
| progress.
|
|
| Questions and Answers
|
| A. Date of administration:
| Location: <.Location.>
| <*Answer_9104*>
|
| B. Method of administration:
| <*Answer_9105*>
|
| 1. In the past 30 days, how would you say your physical health has been?
| <*Answer_9106*>
|
| 2. In the past 30 days, how many nights did you have trouble falling asleep
| or staying asleep?
|
| <*Answer_9113*>
|
| 3. In the past 30 days, how many days have you felt depressed, anxious,
| angry or very upset throughout most of the day?
| <*Answer_9114*>
|
| 4. In the past 30 days, how many days did you drink ANY alcohol?
| <*Answer_9115*>
|
| 5A. In the past 30 days, how many days did you have at least 5 drinks (if
| Veteran: <.Patient_Name_Last_First.>
| 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_9116*>
|
| 5B. In the past 30 days, on the days that you consumed alcohol, what was the
| average number of drinks you consumed on those days?
| <*Answer_9129*>
|
| 5C. In the past 30 days, on the days that you consumed alcohol, what was the
| SSN: <.Patient_SSN.>
| highest number of drinks you consumed in one day?
| <*Answer_9130*>
|
| 6. In the past 30 days, how many days did you use any illegal or street
| drugs or abuse any prescription medications?
| <*Answer_9117*>
|
| 7A. Marijuana (cannabis, pot, weed)?
| <*Answer_9118*>
|
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien,
| barbs, Phenobarbital, downers, etc.)?
| <*Answer_9119*>
|
| 7C. Cocaine and/or Crack?
| <*Answer_9120*>
|
| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin,
| Adderall, speed, crystal meth, ice, etc.)?
| <*Answer_9121*>
|
