337 (337)    MH REPORT (601.93)

|SHORT INVENTORY OF PROBLEMS - AD - Version 2 (SIP-AD-START_V2)
|   Gender: <.Patient_Gender.>
|  I have lost interest in activities and hobbies because of 
|  my drinking or drug use.
|    12a.  Ever:
|         <*Answer_9388*>
|    12b.  In the past 30 days:
|         <*Answer_9389*>
| 
|  My drinking or drug use has gotten in the way of my growth 
|  as a person.
|    13a.  Ever:
|  
|         <*Answer_9390*>
|    13b.  In the past 30 days:
|         <*Answer_9391*>
|
|  My drinking or drug use has damaged my social life, 
|  popularity, or reputation.
|    14a.  Ever:
|         <*Answer_9392*>
|    14b.  In the past 30 days:
|         <*Answer_9393*>
|  SIP-AD LIFETIME TOTAL SCORE = <-LIFETIME SCORE->
|
|  I have spent too much or lost a lot of money because of 
|  my drinking or drug us
|    15a.  Ever:
|         <*Answer_9394*>
|    15b.  In the past 30 days:
|         <*Answer_9395*>
|  
|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.
|  Lifetime Total scores range from 0-15. Higher scores indicate more
|  negative consequences associated with drinking or drug use across
|  the lifetime.
|
| SIP-AD PAST 30-DAY TOTAL SCORE = <-PAST 30-DAY TOTAL SCORE->
|
|  
| Past 30-day total scores range from 0-45. Higher scores indicate more 
| negative consequences associated with drinking or drug use within the 
| past 30 days.
| 
|  
| Questions and Answers:
|
|  I have been unhappy because of my drinking or drug use.
|    1a.  Ever:
|         <*Answer_9366*>
|   Date Given: <.Date_Given.>
|    1b.  In the past 30 days:
|         <*Answer_9367*>
|
|  Because of my drinking or drug use, I have lost weight or not eaten 
|  properly.
|    2a.  Ever:
|       <*Answer_9368*>
|    2b.  In the past 30 days:
|       <*Answer_9369*>
|
|   Clinician: <.Staff_Ordered_By.>
|  I have failed to do what is expected of me because of my drinking or 
|  drug use.
|    3a.  Ever:
|         <*Answer_9370*>
|    3b.  In the past 30 days:
|         <*Answer_9371*>
|
|  When drinking or using drugs, my personality has changed for the 
|  worse.
|    4a.  Ever:
|   Location:  <.Location.>
|         <*Answer_9372*>
|    4b.  In the past 30 days:
|         <*Answer_9373*>
| 
|  I have taken foolish risks when I have been drinking or using drugs.
|    5a.  Ever:
|         <*Answer_9374*>
|    5b.  In the past 30 days:
|         <*Answer_9375*>
|
|  
|  While drinking or using drugs, I have said harsh or cruel things 
|  to someone.
|    6a.  Ever:
|         <*Answer_9376*>
|    6b.  In the past 30 days:
|         <*Answer_9377*>
|
|  When drinking or using drugs, I have done impulsive things that
|  I regretted later.
|    7a.  Ever:
|   Veteran:  <.Patient_Name_Last_First.>
|         <*Answer_9378*>
|    7b.  In the past 30 days:
|         <*Answer_9379*>
|
|  I have had money problems because of my drinking or drug use.
|    8a.  Ever:
|         <*Answer_9380*>
|    8b.  In the past 30 days:
|         <*Answer_9381*>
|
|   SSN: <.Patient_SSN.>
|  My physical appearance has been harmed by my drinking or drug
|  use.
|    9a.  Ever:
|         <*Answer_9382*>
|    9b.  In the past 30 days:
|         <*Answer_9383*>
|
|  My family has been hurt by my drinking or drug use.
|    10a.  Ever:
|         <*Answer_9384*>
|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|    10b.  In the past 30 days:
|         <*Answer_9385*>
|
|  A friendship or close relationship has been damaged by my 
|  drinking or drug use.
|    11a.  Ever:
|         <*Answer_9386*>
|    11b.  In the past 30 days:
|         <*Answer_9387*>
|