324 (324)    MH REPORT (601.93)

|Gambling Symptom Assessment Scale (G-SAS)
|   Gender: <.Patient_Gender.>
|  
|   G-SAS Total Score = <-Score->
|    Total score ranges from 0 - 48.
|       41 - 48 = extreme gambling symptom severity
|       31 - 40 = severe 
|       21 - 30 = moderate
|        8 - 20 = mild
|
|Questions and Answers:
|  
|  
|   1.  If you had unwanted urges to gamble during the past WEEK, on average,
|       how strong were your urges?  Please select the most appropriate number.
|       <*Answer_9214*>
|   2.  During the past WEEK, how many times did you experience urges to 
|       gamble? Please select the most appropriate number.
|       <*Answer_9215*>
|   3.  During the past WEEK, how many hours (add up hours) were you 
|       preoccupied with your urges to gamble? Please select the most 
|       appropriate number.
|   Date Given: <.Date_Given.>
|       <*Answer_9216*>
|   4.  During the past WEEK, how much were you able to control your urges? 
|       Please select the most appropriate number.
|       <*Answer_9217*>
|   5.  During the past WEEK, how often did thoughts about gambling and placing
|       bets come up? Please select the most appropriate answer.
|       <*Answer_9218*>
|   6.  During the past WEEK, approximately how many hours (add up hours) did 
|       you spend thinking about gambling and thinking about placing bets? 
|       Please select the most appropriate number.
|   Clinician: <.Staff_Ordered_By.>
|       <*Answer_9219*>
|   7.  During the past WEEK, how much were you able to control your thoughts
|       of gambling? Please select the most appropriate number.
|       <*Answer_9220*>
|   8.  During the past WEEK, approximately how much total time did you spend
|       gambling or on gambling related activities. Please select the most
|       appropriate number.
|       <*Answer_9221*>
|   9.  During the past WEEK, on average, how much anticipatory tension and/or
|       excitement did you have shortly before you engaged in gambling? If you 
|   Location:  <.Location.>
|       did not actually gamble, please estimate how much tension and/or
|       excitement you believe you would have experienced if you had gambled.
|       Please select the most appropriate number.
|       <*Answer_9222*>
|  10.  During the past WEEK, on average, how much excitement and pleasure did 
|       you feel when you won on your bet. If you did not actually win at 
|       gambling, please estimate how much excitement and pleasure you would 
|       have experienced if you had won. Please select the most appropriate 
|       number.
|       <*Answer_9223*>
|  
|  11.  During the past WEEK, how much emotional distress (mental pain or 
|       anguish, shame, guilt, embarrassment) has your gambling caused you? 
|       Please select the most appropriate number.
|       <*Answer_9224*>
|  12.  During the past WEEK, how much personal trouble (relationship, 
|       financial, legal, job, medical or health) has your gambling caused you?
|       Please select the most appropriate number.
|       <*Answer_9225*>
|  
|Information contained in this note is based on a self-report assessment 
|   Veteran:  <.Patient_Name_Last_First.>
|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.
|   SSN: <.Patient_SSN.>
|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)