| RPT |
.| .| Brief Addiction Monitor: IOP version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
day?| <*Answer_6443*>| | 4. In the past 7 days, how many days did you drink ANY alcohol?| <*Answer_6444*>| | 5. In the past 7 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_6445*>| | 6. In the past 7 days, how many days did you use any illegal or street drugs or abuse any prescription medications?| <*Answer_6446*>| | 7. In the past 7 days,
how many days did you use any of the following drugs:| | 7A. Marijuana (cannabis, pot, weed)?| <*Answer_6447*>| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan,
Ambien, barbs, Phenobarbital, downers, etc.)?| <*Answer_6448*>| 7C. Cocaine and/or Crack?| <*Answer_6449*>| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine,
Ritalin, Adderall, speed, crystal meth, ice, etc.)?| <*Answer_6450*>| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin,
Fentanyl, etc.)?| <*Answer_6451*>| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_6452*>| 7G. Other drugs (steroids, non-prescription
sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?| <*Answer_6453*>| | 8. In the past 7 days, how much were you bothered by cravings or urges to
drink alcohol or use drugs?| <*Answer_6454*>| | 9. How confident are you that you will NOT use alcohol and drugs in the next 7 days?| <*Answer_6455*>| | 10. In the past 7
days, how many days did you attend self-help meetings like AA or NA to support your recovery?| <*Answer_6456*>| | 11. In the past 7 days, how many days were you in any situations or with
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Clinical Subscales:| | Use: <-Use->| Items 4, 5, 6. A high score
any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?| <*Answer_6457*>| | 12. Does your religion or spirituality
help support your recovery?| <*Answer_6458*>| | 13. In the past 7 days, how many days did you spend much of the time at work, school, or doing volunteer work?| <*Answer_6459*>|
| 14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents?| <*Answer_6460*>| |
15. In the past 7 days, how much have you been bothered by arguments or problems getting along with any family members or friends?| <*Answer_6461*>| | 16. In the past 7 days, how many
days did you contact or spend time with any family members or friends who are supportive of your recovery?| <*Answer_6462*>| | 17. How satisfied are you with your progress toward
achieving your recovery goals?| <*Answer_6463*>| | 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.| $~
indicates more use, range is 0 to 12. If a patient scores a 1 or greater, it calls for further assessment and clinical attention, e.g., consider addition/change of pharmacotherapy or psychosocial
intervention. | | Risk Factors: <-Risk Factors->| Items 1, 2, 3, 8, 11, 15. A high score indicates increased risk, range is 0 to 24. Clinicians are encouraged to consider scores on
individual Risk items in offering interventions as indicated during initial treatment planning and following re-assessment.| | Protective Factors: <-Protective Factors->| Items 9,
10, 12, 13, 14, 16. A high score indicates greater protective factors, range is 0 to 24. Clinicians are encouraged to consider scores on individual Protective items in offering interventions as
indicated during initial treatment planning and following re-assessment.| | | Questions and Answers| | A. Date of administration:| <*Answer_6439*>| B. Method of
administration:| <*Answer_6440*>| | 1. In the past 7 days, how would you say your physical health has been?| <*Answer_6441*>| | 2. In the past 7 days, how many nights did
you have trouble falling asleep or staying asleep?| <*Answer_6442*>| | 3. In the past 7 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the
|
