| RPT |
|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*>
|
|
