| RPT |
Brief Addiction Monitor: IOP version for CSG-SUD (BAM-IOP-CSG-SUD)
| Gender: <.Patient_Gender.>
| <*Answer_9144*>
| 7G. Other drugs (steroids, non-prescription sleep and diet pills,
| Benadryl, Ephedra, other over-the-counter or unknown
| medications)?
| <*Answer_9145*>
|
| 8. In the past 7 days, how much were you bothered by cravings or urges
| to drink alcohol or use drugs?
| <*Answer_9146*>
|
|
| 9. How confident are you that you will NOT use alcohol and drugs in the
| next 7 days?
| <*Answer_9147*>
|
| 10. In the past 7 days, how many days did you attend self-help meetings
| like AA or NA to support your recovery?
| <*Answer_9148*>
|
| 11. In the past 7 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_9149*>
|
| 12. Does your religion or spirituality help support your recovery?
| <*Answer_9150*>
|
| 13. In the past 7 days, how many days did you spend much of the time at
| work, school, or doing volunteer work?
| <*Answer_9151*>
|
| Clinical Subscales:
| 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_9152*>
|
| 15. In the past 7 days, how much have you been bothered by arguments or
| problems getting along with any family members or friends?
| <*Answer_9153*>
|
| 16. In the past 7 days, how many days did you contact or spend time with
|
| any family members or friends who are supportive of your recovery?
| <*Answer_9154*>
|
| 17. How satisfied are you with your progress toward achieving your
| recovery goals?
| <*Answer_9155*>
|
| 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
| Use: <-Use->
diagnostic activities and procedures.
| Items 4, 5A, 6. A high score indicates more use, range is 0 to 12. 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 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
| Date Given: <.Date_Given.>
| scores on individual Protective items in offering interventions as
| indicated during initial treatment planning and following
| re-assessment.
|
| Average Drinks (5B): <*Answer_9156*>
| Highest Consumed (5C): <*Answer_9157*>
| Items 5B and 5C should be reviewed and interpreted at the item-level
| and 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
| Clinician: <.Staff_Ordered_By.>
| the frequency of use, risk and protective composite scores, to inform
| treatment planning and treatment progress.
|
| Questions and Answers
|
| A. Date of administration:
| <*Answer_9131*>
| B. Method of administration:
| <*Answer_9132*>
|
| Location: <.Location.>
| 1. In the past 7 days, how would you say your physical health has been?
| <*Answer_9133*>
|
| 2. In the past 7 days, how many nights did you have trouble falling
| asleep or staying asleep?
| <*Answer_9134*>
|
| 3. In the past 7 days, how many days have you felt depressed, anxious,
| angry or very upset throughout most of the day?
| <*Answer_9135*>
|
|
| 4. In the past 7 days, how many days did you drink ANY alcohol?
| <*Answer_9136*>
|
| 5A. In the past 7 days, 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_9137*>
|
| Veteran: <.Patient_Name_Last_First.>
| 5B. In the past 7 days, on the days that you consumed alcohol, what was
| the average number of drinks you consumed on those days?
| <*Answer_9156*>
|
| 5C. In the past 7 days, on the days that you consumed alcohol, what was
| the highest number of drinks you consumed in one day?
| <*Answer_9157*>
|
| 6. In the past 7 days, how many days did you use any illegal or street
| drugs or abuse any prescription medications?
| SSN: <.Patient_SSN.>
| <*Answer_9138*>
|
| 7. In the past 7 days, how many days did you use any of the following
| drugs:
|
| 7A. Marijuana (cannabis, pot, weed)?
| <*Answer_9139*>
| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan,
| Ambien, barbs, Phenobarbital, downers, etc.)?
| <*Answer_9140*>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| 7C. Cocaine and/or Crack?
| <*Answer_9141*>
| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine,
| Ritalin, Adderall, speed, crystal meth, ice, etc.)?
| <*Answer_9142*>
| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy,
| codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?
| <*Answer_9143*>
| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner,
| etc.)?
|
