| RPT |
|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.>)
|
