| RPT |
.| .| Brief Addiction Monitor - Consumption Items| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, "speed", "crystal meth", "ice", etc.)?| <*Answer_6470*>| | 4E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy,
codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?| <*Answer_6471*>| | 4F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_6472*>|
| 4G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?| <*Answer_6473*>| | | 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.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>||| Days Alcohol Use: <-Days Alcohol Use->| Days of Heavy Alcohol Use: <-Days Heavy Alcohol Use->| Days Other Drug Use: <-Days
Other Drug Use->|| Range is 0 to 30. If a patient scores a 1 or greater, it calls for | further examination and clinical attention, e.g. consider addition of| pharmacotherapy or higher level of care, add motivational interviewing.|
| Questions and Answers| | A. Date of administration:|
<*Answer_6399*>| B. Method of administration:| <*Answer_6400*>| | 1. In the past 30 days, how many days did you drink ANY alcohol?| <*Answer_6464*>| | 2. In the past 30 days,
how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce can/bottle of beer
or 5-ounce glass of wine.] | <*Answer_6465*>| | 3. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?| <*Answer_6466*>|
| 4. In the past 30 days, how many days did you use any of the following drugs: | 4A. Marijuana (cannabis, pot, weed)?| <*Answer_6467*>| | 4B. Sedatives and/or Tranquilizers
(benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?| <*Answer_6468*>| | 4C. Cocaine and/or Crack?| <*Answer_6469*>| | 4D. Other Stimulants (e.g.,
|
