6 (6)    MH REPORT (601.93)

.|.|The Alcohol, Smoking and Substance Involvement Test||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: 
methadone, codeine, etc.)|    <*Answer_3960*>| 1j. Other|    <*Answer_3961*>|  Specify:|    <*Answer_3964*>||2. In the past three months, how often have you used the substances you mentioned?| 2a. 
Tobacco products (cigarettes, chewing tobacco, cigars, etc.)|    <*Answer_3965*>| 2b. Alcoholic beverages (beer, wine, spirits, etc.)|    <*Answer_3969*>| 2c. Cannabis (marijuana, pot, grass, hash, 
etc.)|    <*Answer_3970*>| 2d. Cocaine (coke, crack, etc.)|    <*Answer_3971*>| 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)|    <*Answer_3988*>| 2f. Inhalants (nitrous, glue, 
petrol, paint thinner, etc.)|    <*Answer_3990*>| 2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    <*Answer_3991*>| 2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, 
etc.)|    <*Answer_3992*>| 2i. Opioids (heroin, morphine, methadone, codeine, etc.)|    <*Answer_3993*>| 2j. Other (as specified previously)|    <*Answer_3994*>||3. During the past three months, how 
often have you had a strong desire or urge to use the drug(s)?| 3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)|    <*Answer_3995*>| 3b. Alcoholic beverages (beer, wine, spirits, 
etc.)|    <*Answer_3996*>| 3c. Cannabis (marijuana, pot, grass, hash, etc.)|    <*Answer_3997*>| 3d. Cocaine (coke, crack, etc.)|    <*Answer_3998*>| 3e. Amphetamine type stimulants (speed, diet 
pills, ecstasy, etc.)|    <*Answer_3999*>| 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)|    <*Answer_4000*>| 3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    
<*Answer_4001*>| 3h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|    <*Answer_4002*>| 3i. Opioids (heroin, morphine, methadone, codeine, etc.)|    <*Answer_4003*>| 3j. Other (as 
specified previously)|    <*Answer_4007*>||4. During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems?| 4a. Tobacco 
<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||ASSIST Scores||   Tobacco: <-Tobacco->       0-3 Low risk,  4-26 Moderate,  27+ High   |   Alcohol: 
products (cigarettes, chewing tobacco, cigars, etc.)|    <*Answer_4008*>| 4b. Alcoholic beverages (beer, wine, spirits, etc.)|    <*Answer_4009*>| 4c. Cannabis (marijuana, pot, grass, hash, etc.)|    
<*Answer_4010*>| 4d. Cocaine (coke, crack, etc.)|    <*Answer_4011*>| 4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)|    <*Answer_4012*>| 4f. Inhalants (nitrous, glue, petrol, 
paint thinner, etc.)|    <*Answer_4013*>| 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    <*Answer_4014*>| 4h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|    
<*Answer_4017*>| 4i. Opioids (heroin, morphine, methadone, codeine, etc.)|    <*Answer_4018*>| 4j. Other (as specified previously)|    <*Answer_4020*>||5. During the past three months, how often have 
you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)?| 5a. Tobacco products|    <*Answer_4021*>| 5b. Alcoholic beverages (beer, wine, spirits, 
etc.)|    <*Answer_4023*>| 5c. Cannabis (marijuana, pot, grass, hash, etc.)|    <*Answer_4024*>| 5d. Cocaine (coke, crack, etc.)|    <*Answer_4025*>| 5e. Amphetamine type stimulants (speed, diet 
pills, ecstasy, etc.)|    <*Answer_4026*>| 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)|    <*Answer_4027*>| 5g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    
<*Answer_4028*>| 5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|    <*Answer_4029*>| 5i. Opioids (heroin, morphine, methadone, codeine, etc.)|    <*Answer_4030*>| 5j. Other (as 
previous specified)|    <*Answer_4031*>||6. Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)?| 6a. Tobacco products (cigarettes, 
chewing tobacco, cigars, etc.)|    <*Answer_4032*>| 6b. Alcoholic beverages (beer, wine, spirits, etc.)|    <*Answer_4034*>| 6c. Cannabis (marijuana, pot, grass, hash, etc.)|    <*Answer_4044*>| 6d. 
<-Alcohol->       0-10 Low risk, 11-26 Moderate, 27+ High     |   Cannabis: <-Cannabis->      0-3 Low risk,  4-26 Moderate,  27+ High|   Cocaine: <-Cocaine->       0-3 Low risk,  4-26 Moderate,  27+ 
Cocaine (coke, crack, etc.)|    <*Answer_4045*>| 6e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)|    <*Answer_4046*>| 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)|    
<*Answer_4047*>| 6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    <*Answer_4048*>| 6h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|    <*Answer_4049*>| 6i. Opioids 
(heroin, morphine, methadone, codeine, etc.)|    <*Answer_4050*>| 6j. Other (as previously specified)|    <*Answer_4051*>||7. Have you ever tried and failed to control, cut down or stop using (FIRST 
DRUG, SECOND DRUG, ETC.)?| 7a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)|    <*Answer_4052*>| 7b. Alcoholic beverages (beer, wine, spirits, etc.)|    <*Answer_4053*>| 7c. Cannabis 
(marijuana, pot, grass, hash, etc.)|    <*Answer_4054*>| 7d. Cocaine (coke, crack, etc.)|    <*Answer_4055*>| 7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)|    <*Answer_4086*>| 
7f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)|    <*Answer_4087*>| 7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    <*Answer_4088*>| 7h. Hallucinogens (LSD, acid, 
mushrooms, PCP, Special K, etc.)|    <*Answer_4089*>| 7i. Opioids (heroin, morphine, methadone, codeine, etc.)|    <*Answer_4090*>| 7j. Other (as previously specified)|    <*Answer_4189*>||8. Have 
you ever used any drug by injection? (Non-medical use only)|    <*Answer_4237*>| 8a. What is your pattern of injecting?|    <*Answer_4254*>|||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 and 
procedures.|          $~
High|   Amphetamine: <-Amphetamine->   0-3 Low risk,  4-26 Moderate,  27+ High|   Inhalants: <-Inhalants->     0-3 Low risk,  4-26 Moderate,  27+ High|   Sedatives: <-Sedatives->     0-3 Low risk,  
4-26 Moderate,  27+ High|   Hallucingens: <-Hallucingens->  0-3 Low risk,  4-26 Moderate,  27+ High|   Opioids: <-Opioids->       0-3 Low risk,  4-26 Moderate,  27+ High|   Other: <-Other->         
0-3 Low risk,  4-26 Moderate,  27+ High||Questions and Answers||1. In your life, which of the following substances have you ever used?| 1a. Tobacco products (cigarettes, chewing tobacco, cigars, 
etc.)|    <*Answer_3934*>| 1b. Alcoholic beverages (beer, wine, spirits, etc.)|    <*Answer_3935*>| 1c. Cannabis (marijuana, pot, grass, hash, etc.)|    <*Answer_3936*>| 1d. Cocaine (coke, crack, 
etc.)|    <*Answer_3937*>| 1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)|    <*Answer_3945*>| 1f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)|    <*Answer_3956*>| 1g. 
Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)|    <*Answer_3957*>| 1h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)|    <*Answer_3958*>| 1i. Opioids (heroin, morphine,