| RPT |
|SHORT INVENTORY OF PROBLEMS - AD - Version 2 (SIP-AD-30_V2)
| Gender: <.Patient_Gender.>
|
|
|SIP-AD-30_V2 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:
|
|
| 1. I have been unhappy because of my drinking or drug use.
| <*Answer_9350*>
| 2. Because of my drinking or drug use, I have lost weight or not
| eaten properly.
| <*Answer_9351*>
| 3. I have failed to do what is expected of me because of my drinking
| or drug use.
| <*Answer_9352*>
| 4. When drinking or using drugs, my personality has changed for the
| Date Given: <.Date_Given.>
| worse.
| <*Answer_9353*>
| 5. I have taken foolish risks when I have been drinking or using drugs.
| <*Answer_9354*>
| 6. While drinking or using drugs, I have said harsh or cruel things
| to someone.
| <*Answer_9355*>
| 7. When drinking or using drugs, I have done impulsive things that I
| regretted later.
| <*Answer_9356*>
| Clinician: <.Staff_Ordered_By.>
| 8. I have had money problems because of my drinking or drug use.
| <*Answer_9357*>
| 9. My physical appearance has been harmed by my drinking or drug use.
| <*Answer_9358*>
| 10. My family has been hurt by my drinking or drug use.
| <*Answer_9359*>
| 11. A friendship or close relationship has been damaged by my drinking
| or drug use.
| <*Answer_9360*>
| 12. I have lost interest in activities and hobbies because of my drinking
| Location: <.Location.>
| or drug use.
| <*Answer_9361*>
| 13. My drinking or drug use has gotten in the way of my growth as a
| person.
| <*Answer_9362*>
| 14. My drinking or drug use has damaged my social life, popularity, or
| reputation.
| <*Answer_9363*>
| 15. I have spent too much or lost a lot of money
| <*Answer_9364*>
|
|
|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.
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
