{"aaData": [["1", "PC PTSD\n", "\n.| .| Primary Care PTSD Screen| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | PC PTSD Screen Score: <-PC PTSD Total->| | <*Answer_999999999999*>| | | Questions and Answers| | 1. Have had any nightmares about it or \nthought about it when you did not want to?| <*Answer_3826*>| 2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?| <*Answer_3827*>| 3. Were \nconstantly on guard, watchful, or easily startled?| <*Answer_3828*>| 4. Felt numb or detached from others, activities, or your surroundings?| <*Answer_3829*>| | | Information contained in \nthis 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 \ndiagnostic activities and procedures.| $~\n
\n\n"], ["10", "File: 601.71, IEN: 100108\n", "\n WHYMPI Date Given: <.Date Given.> Clinician: <.Staff: Ordered By.> Location: <.Location.> Veteran: <.Patient Name: Last, First.> SSN: <.Patient: SSN.> DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>) Gender: <.Patient: Gender.> This is a sample report to help you get started. <.Patient: Gender.> Done. <_Script_1_> $~ <_Script_1_>=Please indicate who your significant other is:`101620`1. Spouse`100979`Equals``````Testr script.~\n
\n\n"], ["100", "D.BAS\n", "\n.| .| Dysfunctional Beliefs and Attitudes about Sleep| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n<*Answer_6599*>| 12. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.| <*Answer_6600*>| 13. I \nbelieve insomnia is essentially the result of a chemical imbalance.| <*Answer_6601*>| 14. I feel insomnia is ruining my ability to enjoy life and prevents me from doing what I want.| \n<*Answer_6602*>| 15. Medication is probably the only solution to sleeplessness.| <*Answer_6603*>| 16. I avoid or cancel obligations (social, family) after a poor nights sleep.| \n<*Answer_6604*>| | (c) Copyright: Monin, C. 1993| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | The score is the average of the answered items. A high score indicates a belief \nthat sleep disruption is maladaptive.| | | Questions and Answers| | 1. I need 8 hours of sleep to feel refreshed and function well during the day.| <*Answer_6589*>| 2. When I don't get proper \namount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.| <*Answer_6590*>| 3. I am concerned that chronic insomnia may have serious \nconsequences on my physical health.| <*Answer_6591*>| 4. I am worried that I may lose control over my abilities to sleep.| <*Answer_6592*>| 5. After a poor nights sleep, I know that it will \ninterfere with my daily activities on the next day.| <*Answer_6593*>| 6. In order to be alert and function well during the day, I believe I would be better off taking a sleeping pill rather than \nhaving a poor nights sleep.| <*Answer_6594*>| 7. When I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before.| <*Answer_6595*>| 8. \nWhen I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.| <*Answer_6596*>| 9. Without an adequate nights sleep, I can hardly function the next day.| \n<*Answer_6597*>| 10. I cant ever predict whether Ill have a good or poor nights sleep.| <*Answer_6598*>| 11. I have little ability to manage the negative consequences of disturbed sleep.| \n
\n\n"], ["101", "WHOQOL BREF\n", "\n.| .| World Health Organization: Quality of Life - BREF (WHOQOL-BREF)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nDomain 3: Social relationships <*Answer_7775*>|\nDomain 4: Environment <*Answer_7776*>|\n||\n| | | | Questions and Answers| | 1. How would you rate your quality of life?|\n <*Answer_6605*>| 2. How satisfied are you with your health?| <*Answer_6606*>| 3. To what extent do you feel that physical pain prevents you from doing what you need to do?| <*Answer_6607*>| \n4. How much do you need any medical treatment to function in your daily life?| <*Answer_6608*>| 5. How much do you enjoy life?| <*Answer_6609*>| 6. To what extent do you feel your life to be \nmeaningful?| <*Answer_6610*>| 7. How well are you able to concentrate?| <*Answer_6611*>| 8. How safe do you feel in your daily life?| <*Answer_6612*>| 9. How healthy is your physical \nenvironment?| <*Answer_6613*>| 10. Do you have enough energy for everyday life?| <*Answer_6614*>| 11. Are you able to accept your bodily appearance?| <*Answer_6615*>| 12. Have you enough \nmoney to meet your needs?| <*Answer_6616*>| 13. How available to you is the information that you need in your day-to-day life?| <*Answer_6617*>| 14. To what extent do you have the opportunity \nfor leisure activities?| <*Answer_6618*>| 15. How well are you able to get around?| <*Answer_6619*>| 16. How satisfied are you with your sleep?| <*Answer_6620*>| 17. How satisfied are you \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | |\nwith your ability to perform your daily living activities?| <*Answer_6621*>| 18. How satisfied are you with your capacity for work?| <*Answer_6622*>| 19. How satisfied are you with yourself?| \n <*Answer_6623*>| 20. How satisfied are you with your personal relationships?| <*Answer_6624*>| 21. How satisfied are you with your sex life?| <*Answer_6625*>| 22. How satisfied are you \nwith the support you get from your friends?| <*Answer_6626*>| 23. How satisfied are you with the conditions of your living place?| <*Answer_6627*>| 24. How satisfied are you with your access \nto health services?| <*Answer_6628*>| 25. How satisfied are you with your transport?| <*Answer_6629*>| 26. How often do you have negative feelings such as blue mood, despair, anxiety, \ndepression?| <*Answer_6630*>| 27. Do you have any comments about the assessment? Type "none" or "NA" for no comment.| <*Answer_6631*>| | | Information contained in this note is based on a \nself-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in \nconjunction with other diagnostic activities.||\n World Health Organization 2004|\n| $~\nHigher scores indicate higher quality of life.||\nItem/Domain Veteran's Raw Score Transformed Score|\nItem 1: Overall Quality of Life <*Answer_7771*> N/A|\nItem 2: General Health <*Answer_7772*> N/A|\nSatisfaction |\nDomain 1: Physical Health <*Answer_7773*>|\nDomain 2: Psychological <*Answer_7774*>|\n
\n\n"], ["102", "WHOQOL BREF\n", "\n.| .| World Health Organization: Quality of Life - BREF| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n <*Answer_6623*>| 20. How satisfied are you with your personal relationships?| <*Answer_6624*>| 21. How satisfied are you with your sex life?| <*Answer_6625*>| 22. How satisfied are you \nwith the support you get from your friends?| <*Answer_6626*>| 23. How satisfied are you with the conditions of your living place?| <*Answer_6627*>| 24. How satisfied are you with your access \nto health services?| <*Answer_6628*>| 25. How satisfied are you with your transport?| <*Answer_6629*>| 26. How often do you have negative feelings such as blue mood, despair, anxiety, \ndepression?| <*Answer_6630*>| 27. Do you have any comments about the assessment? Type "none" or "NA" for no comment.| <*Answer_6631*>| | | Information contained in this note is based on a \nself-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 \nprocedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | Questions and Answers| | 1. How would you rate your quality of life?| \n<*Answer_6605*>| 2. How satisfied are you with your health?| <*Answer_6606*>| 3. To what extent do you feel that physical pain prevents you from doing what you need to do?| <*Answer_6607*>| \n4. How much do you need any medical treatment to function in your daily life?| <*Answer_6608*>| 5. How much do you enjoy life?| <*Answer_6609*>| 6. To what extent do you feel your life to be \nmeaningful?| <*Answer_6610*>| 7. How well are you able to concentrate?| <*Answer_6611*>| 8. How safe do you feel in your daily life?| <*Answer_6612*>| 9. How healthy is your physical \nenvironment?| <*Answer_6613*>| 10. Do you have enough energy for everyday life?| <*Answer_6614*>| 11. Are you able to accept your bodily appearance?| <*Answer_6615*>| 12. Have you enough \nmoney to meet your needs?| <*Answer_6616*>| 13. How available to you is the information that you need in your day-to-day life?| <*Answer_6617*>| 14. To what extent do you have the opportunity \nfor leisure activities?| <*Answer_6618*>| 15. How well are you able to get around?| <*Answer_6619*>| 16. How satisfied are you with your sleep?| <*Answer_6620*>| 17. How satisfied are you \nwith your ability to perform your daily living activities?| <*Answer_6621*>| 18. How satisfied are you with your capacity for work?| <*Answer_6622*>| 19. How satisfied are you with yourself?| \n
\n\n"], ["103", "ISI\n", "\n.| .| Insomnia Severity Index| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | ISI score: <-ISI->| | Score categories:| 0 - 7 No clinically significant insomnia| 8 - 14 Subthreshold \ninsomnia| 15 - 21 Clinical insomnia (moderate severity)| 22 - 28 Clinical insomnia (severe)| | Questions and Answers| | 1. Difficulty falling asleep.| <*Answer_6632*>| 2. Difficulty \nstaying asleep.| <*Answer_6633*>| 3. Problems waking up too early.| <*Answer_6634*>| 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?| <*Answer_6635*>| 5. How \nNOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?| <*Answer_6636*>| 6. How WORRIED/DISTRESSED are you about your current sleep problem?| \n<*Answer_6637*>| 7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, \nmemory, mood, etc.) CURRENTLY? | <*Answer_6638*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["104", "SPSI-R S\n", "\n.| .| Social Problem-Solving Inventory--Revised, Short Form| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | 1. <*Answer_6639*> 2. \n<*Answer_6640*> 3. <*Answer_6641*> | 4. <*Answer_6642*> 5. <*Answer_6643*> 6. <*Answer_6644*> | 7. <*Answer_6645*> 8. <*Answer_6646*> 9. <*Answer_6647*> | 10. <*Answer_6648*> 11. \n<*Answer_6649*> 12. <*Answer_6650*> | 13. <*Answer_6651*> 14. <*Answer_6652*> 15. <*Answer_6653*>| 16. <*Answer_6654*> 17. <*Answer_6655*> 18. <*Answer_6656*> | 19. <*Answer_6657*> 20. \n<*Answer_6658*> 21. <*Answer_6659*> | 22. <*Answer_6660*> 23. <*Answer_6661*> 24. <*Answer_6662*> | 25. <*Answer_6663*>| | Copyright (c) 1996, 2002 Multi-Health Systems, Inc. All rights \nreserved.| | 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 \nand used in conjunction with other diagnostic activities and procedures.| | | $~\n
\n\n"], ["105", "RLS\n", "\n.| .| Restless Legs Syndrome Rating Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nshould be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | RLS Score: <-RLS->| | | Scoring:| Mild (1 - 10)| Moderate (11 - 20)| \n Severe (21 - 30)| Very severe (31 - 40) | | Questions and Answers| | 1. Overall, how would you rate the RLS discomfort in your legs or arms?| <*Answer_6664*>| 2. Overall, how \nwould you rate the need to move around because of your RLS symptoms?| <*Answer_6665*>| 3. Overall, how much relief of your RLS arm or leg discomfort did you get from moving around?| \n<*Answer_6666*>| 4. How severe was your sleep disturbance due to your RLS symptoms?| <*Answer_6667*>| 5. How severe was your tiredness or sleepiness during the day due to your RLS \nsymptoms?| <*Answer_6668*>| 6. How severe was your RLS as a whole?| <*Answer_6669*>| 7. How often did you get RLS symptoms?| <*Answer_6670*>| 8. When you had RLS symptoms, how \nsevere were they on average?| <*Answer_6671*>| 9. Overall, how severe was the impact of your RLS symptoms on your ability to carry out your daily affairs, for example, carrying out a \nsatisfactory family, home, social, school or work life?| <*Answer_6672*>| 10. How severe was your mood disturbance due to your RLS symptoms - for example, angry, depressed, sad, anxious or \nirritable?| <*Answer_6673*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results \n
\n\n"], ["106", "RLS\n", "\n.| .| Restless Legs Syndrome Rating Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | ||Scoring: 1-10 Mild RLS 11-20 Moderate RLS| 21-30 Severe RLS| 31-40 Very severe| | RLS| \n RLS: <-RLS->| 1. <*Answer_6664*>| 2. <*Answer_6665*>| 3. <*Answer_6666*>| 4. <*Answer_6667*>| 5. <*Answer_6668*>| 6. <*Answer_6669*>| 7. <*Answer_6670*>| 8. <*Answer_6671*>| 9. <*Answer_6672*>| 10. \n<*Answer_6673*>| | | 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 \naccuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["107", "RLS\n", "\n.| .| Restless Legs Syndrome Rating Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | ||Scoring: 1-10 Mild RLS 11-20 Moderate RLS| 21-30 Severe RLS| 31-40 Very severe| | RLS| \n RLS: <-RLS->| | 1. <*Answer_6664*>| 2. <*Answer_6665*>| 3. <*Answer_6666*>| 4. <*Answer_6667*>| 5. <*Answer_6668*>| 6. <*Answer_6669*>| 7. <*Answer_6670*>| 8. <*Answer_6671*>| 9. <*Answer_6672*>| \n10. <*Answer_6673*>| | | 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 \naccuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["108", "CSM\n", "\n.| .| Smith Morningness/Eveningness Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \n <*Answer_6681*>| 9. One hears about "morning" and "evening" type people. Which ONE of these types do you consider yourself to be?| <*Answer_6682*>| 10. When would you prefer to rise (provided \nyou have a full day's work - 8 hours) if you were totally free to arrange your time?| <*Answer_6683*>| 11. If you always had to rise at 6:00 am, what do you think it would be like?| \n<*Answer_6684*>| 12. How long a time does it usually take before you "recover your senses" in the morning after rising from a night's sleep?| <*Answer_6685*>| 13. Please indicate to what extent \nyou are a morning or an evening active individual?| <*Answer_6686*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Scoring:| | 22 and less - evening type| 23 - 43 - intermediate type| 44 and \nabove - morning type| | | CSM Score: <-CSM->| | | Questions and Answers| | 1. Considering only your own "feeling best" rhythm, at what time would you get up if you were entirely \nfree to plan your day?| <*Answer_6674*>| 2. Considering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?| \n<*Answer_6675*>| 3. Assuming normal circumstances, how easy do you find getting up in the morning?| <*Answer_6676*>| 4. How alert do you feel after the first half hour after having awakened in \nthe morning?| <*Answer_6677*>| 5. During the first half hour after having awakened in the morning, how tired do you feel?| <*Answer_6678*>| 6. You have decided to engage in some physical \nexercise. A friend suggests that you do this one hour twice a week and the best time for him is 7:00-8:00 am. Bearing in mind nothing else but your "feeling best" rhythm, how do you think you \nwould perform? | <*Answer_6679*>| 7. At what time in the evening do you feel tired and as a result, in need of sleep?| <*Answer_6680*>| 8. You wish to be at your peak performance for a two \nhour test, which will be mentally exhausting. You are entirely free to plan your day, and considering only your own "feeling best" rhythm, which ONE of the four testing times would you choose? | \n
\n\n"], ["109", "QOLIE-10\n", "\n.| .| QOLIE-10| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> \nServices and the QOLIE| Development Group.| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n(<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | QOLIE - 10: <-QOLIE - 10->| | Questions and Answers| | 1. Did you have a lot of energy?| <*Answer_6687*>| 2. Have you felt downhearted and \nlow?| <*Answer_6688*>| 3. Driving (or other transport)?| <*Answer_6689*>| 4. How much do your work limitations bother you?| <*Answer_6690*>| 5. How much do your social limitations bother \nyou?| <*Answer_6691*>| 6. How much do your memory difficulties bother you?| <*Answer_6692*>| 7. How much do physical effects of antiepileptic drugs bother you?| <*Answer_6693*>| 8. How \nmuch do psychological effects of antiepileptic drugs bother you?| <*Answer_6694*>| 9. How afraid are you of having a seizure during the next 4 weeks?| <*Answer_6695*>| 10. How has your \nQUALITY OF LIFE been during the past 4 weeks (that is, how have things been going for you)?| <*Answer_6696*>| 11. How much does the state of your epilepsy-related quality of life distress you \noverall?| <*Answer_7176*>| 12a. Energy (tiredness)| <*Answer_7177*>| 12b. Emotions (mood)| <*Answer_7178*>| 12c. Daily activities (work, driving, social)| <*Answer_7179*>| 12d. Mental \nactivity (thinking, concentrating, memory)| <*Answer_7180*>| 12e. Medication effects (physical, mental)| <*Answer_7181*>| 12f. Worry about fits (impact of fits)| <*Answer_7182*>| 12g. \nOverall quality of life| <*Answer_7183*>| | copyright (c) 1996, Epilepsy Therapy Project, QOLIE Development Group; Adapted from | the QOLIE-10,copyright (c) 1993, Professional Postgraduate \n
\n\n"], ["11", "PCLS\n", "\n.|.|PTSD Checklist Stressor Specific||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nIMPORTANT PARTS of the stressful experience?| <*Answer_5167*>|9. LOSS of INTEREST in activities that you used to enjoy?| <*Answer_5168*>|10. Feeling DISTANT or CUT OFF from other people?| \n<*Answer_5169*>|11. Feeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?| <*Answer_5170*>|12. Feeling as if your FUTURE somehow will be CUT SHORT?| \n<*Answer_5171*>|13. Trouble FALLING or STAYING ASLEEP?| <*Answer_5172*>|14. Feeling IRRITABLE or having ANGRY OUTBURSTS?| <*Answer_5173*>|15. Having DIFFICULTY CONCENTRATING?| \n<*Answer_5174*>|16. Being "SUPERALERT" or watchful or on guard?| <*Answer_5175*>|17. Feeling JUMPY or easily startled?| <*Answer_5176*>|||Information contained in this note is based on a \nself-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 \nprocedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||PCLS Score: <-Score->||The score has a range of 17 to 85. A cutoff score is relevant to these populations.| VA PTSD \nspecialty mental health clinic: Screening-48 Diagnosis-56 | VA primary care clinic: Screening-25 Diagnosis-33 | Active duty Iraq/Afghanistan (OEF/OIF) Screening-25 Diagnosis-28 | Civilian \nsubstance abuse residential: Screening-36 Diagnosis-44 | Civilian primary care: Screening-25 Diagnosis-30-38 | Civilian motor vehicle accidents: Screening-44 Diagnosis-50||Questions and \nAnswers||A. The event you experienced was:| <*Answer_5158*>|B. Date of the event:| <*Answer_5159*>|1. Repeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?| \n<*Answer_5160*>|2. Repeated disturbing DREAMS of the stressful experience?| <*Answer_5161*>|3. Suddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if \nyou were reliving it)?| <*Answer_5162*>|4. Feeling VERY UPSET when SOMETHING reminded you of the stressful experience?| <*Answer_5163*>|5. Having PHYSICAL reactions (e.g. heart pounding, \ntrouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?| <*Answer_5164*>|6. Avoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or \nAVOIDING HAVING FEELINGS related to it?| <*Answer_5165*>|7. Avoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?| <*Answer_5166*>|8. Trouble REMEMBERING \n
\n\n"], ["110", "SBR II\n", "\n.| .| Suicide Behavior Report| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n 15. Inpatient unit at time of event:| <*Answer_6728*>| 15A. Inpatient status at time of event:| <*Answer_6729*>| 16. Brief Plan or Disposition (Check all that apply):| \n<*Answer_6730*>| 16A. Any other plan or disposition not listed above? (If none, type "None")| <*Answer_6731*>| 17. Is there any indication that the person engaged in self-directed violent \nbehavior, either preparatory or potentially harmful?| <*Answer_6697*>| 18. Is there any indication that the person had self-directed violence related thoughts?| <*Answer_6698*>| 18A. \nWere/Are the thoughts suicidal?| <*Answer_6699*>| 19. Did the behavior involve any injury?| <*Answer_6700*>| 19A. Was the injury fatal?| <*Answer_6701*>| 19B. Was the behavior \npreparatory only?| <*Answer_6702*>| 19C. Was the behavior interrupted by self or other(s)?| <*Answer_6703*>| 20. Is there evidence of suicidal intent?| <*Answer_6704*>| | | \nInformation 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 \nconjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Date and Time of event:| <*Answer_6705*>| 2. Brief description \nof event:| <*Answer_6706*>| 3. Location of event::| <*Answer_6707*>| 4. Veteran status at time of event:| <*Answer_6708*>| 5. Veteran status following the event:| \n<*Answer_6709*>| 5A. Hospitalized at:| <*Answer_6710*>| 6. Method of information:| <*Answer_6711*>| 7. Source of information:| <*Answer_6712*>| 7A. Specify "Other"| \n<*Answer_6713*>| 7B. Name and phone of source:| <*Answer_6714*>| 8. Last Pain Score:| <*Answer_6715*>| 9. Did the veteran have access to firearms?| <*Answer_6716*>| 10. Family \nand other supports available at time of event:| <*Answer_6717*>| 10A. Other support:| <*Answer_6718*>| 11. Treatment plan changes implemented due to the event:| <*Answer_6719*>| \n11A. Describe / Other| <*Answer_6720*>| 12. Past 10 clinic visits:| <*Answer_6721*>| 13. Veteran was receiving treatment in the following area(s) at the time of this event:| \n<*Answer_6722*>| 13A. Name any specialty clinic(s) veteran was receiving treatment at time of this event (if none, type "None"):| <*Answer_6723*>| 13B. Primary Care Provider:| \n<*Answer_6724*>| 13C. Case Manager / Therapist:| <*Answer_6725*>| 13D. Provider prescribing psychiatric medications:| <*Answer_6726*>| 14. Active Problem List:| <*Answer_6727*>| \n
\n\n"], ["111", "ASSIST-WHOV3\n", "\n.| .| The Alcohol, Smoking and Substance Involvement Screening Test| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \nPCP, Special K, etc.)| <*Answer_3958*>| 1i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_3960*>| 1j. Other| <*Answer_3961*>| Specify:| <*Answer_3964*>| | \n2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)?| | 2a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| \n<*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.)| \n <*Answer_3971*>| 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3988*>| 2f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3990*>| \n2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3991*>| 2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_3992*>| 2i. Opioids (heroin, \nmorphine, 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 \nurge to use (FIRST DRUG, SECOND DRUG, ETC)?| | 3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3995*>| 3b. Alcoholic beverages (beer, wine, spirits, etc.)| \n<*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, \necstasy, etc.)| <*Answer_3999*>| 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4000*>| 3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| \n<*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 \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | ASSIST Scores:| | Tobacco: <-Tobacco->| Alcohol: \nspecified 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. \nTobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4008*>| 4b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4009*>| 4c. Cannabis (marijuana, pot, grass, \nhash, etc.)| <*Answer_4010*>| 4d. Cocaine (coke, crack, etc.)| <*Answer_4011*>| 4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4012*>| 4f. Inhalants \n(nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4013*>| 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4014*>| 4h. Hallucinogens (LSD, acid, mushrooms, \nPCP, Special K, etc.)| <*Answer_4017*>| 4i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4018*>| 4j. Other (as specified previously)| <*Answer_4020*>| | 5. During \nthe 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. \nAlcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4023*>| 5c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4024*>| 5d. Cocaine (coke, crack, etc.)| <*Answer_4025*>| \n 5e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4026*>| 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4027*>| 5g. Sedatives or \nSleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4028*>| 5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4029*>| 5i. Opioids (heroin, morphine, \nmethadone, 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 \n<-Alcohol->| Cannabis: <-Cannabis->| Cocaine: <-Cocaine->| Amphetamine: <-Amphetamine->| Inhalants: <-Inhalants->| Sedatives: <-Sedatives->| Hallucingens: <-Hallucingens->| \n(FIRST DRUG, SECOND DRUG, ETC.)?| | 6a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4032*>| 6b. Alcoholic beverages (beer, wine, spirits, etc.)| \n<*Answer_4034*>| 6c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4044*>| 6d. Cocaine (coke, crack, etc.)| <*Answer_4045*>| 6e. Amphetamine type stimulants (speed, diet pills, \necstasy, etc.)| <*Answer_4046*>| 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4047*>| 6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| \n<*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 \npreviously 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 \ntobacco, cigars, etc.)| <*Answer_4052*>| 7b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4053*>| 7c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4054*>| 7d. \nCocaine (coke, crack, etc.)| <*Answer_4055*>| 7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4086*>| 7f. Inhalants (nitrous, glue, petrol, paint thinner, \netc.)| <*Answer_4087*>| 7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4088*>| 7h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| \n<*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 \ninjection? (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 \n Opioids: <-Opioids->| Other: <-Other->| | For all scores except Alcohol:| 0-3 Low risk for health and other problems| 4-26 Moderate risk for health and other problems| 27+ \nand 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.| $~\nHigh risk for severe problems and likely to be addicted| | Alcohol score:| 0-10 Low risk for health and other problems| 11-26 Moderate risk for health and other problems| 27+ High \nrisk for severe problems and likely to be addicted| | | | Questions and Answers| | 1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)| | 1a. Tobacco \nproducts (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3934*>| 1b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3935*>| 1c. Cannabis (marijuana, pot, grass, hash, \netc.)| <*Answer_3936*>| 1d. Cocaine (coke, crack, etc.)| <*Answer_3937*>| 1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3945*>| 1f. Inhalants \n(nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3956*>| 1g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3957*>| 1h. Hallucinogens (LSD, acid, mushrooms, \n
\n\n"], ["112", "ASSIST-WHOV3\n", "\n.| .| The Alcohol, Smoking and Substance Involvement Screening Test| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nETC)?| | 2a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3965*>| 2b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3969*>| 2c. Cannabis (marijuana, pot, \ngrass, hash, etc.)| <*Answer_3970*>| 2d. Cocaine (coke, crack, etc.)| <*Answer_3971*>| 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3988*>| 2f. Inhalants \n(nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3990*>| 2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3991*>| 2h. Hallucinogens (LSD, acid, mushrooms, \nPCP, Special K, etc.)| <*Answer_3992*>| 2i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_3993*>| 2j. Other (as specified previously)| <*Answer_3994*>| | 3. During the \npast three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)?| | 3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3995*>| 3b. \nAlcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3996*>| 3c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3997*>| 3d. Cocaine (coke, crack, etc.)| <*Answer_3998*>| 3e. \nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3999*>| 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4000*>| 3g. Sedatives or Sleeping Pills \n(Valium, Serepax, Rohypnol, etc.)| <*Answer_4001*>| 3h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4002*>| 3i. Opioids (heroin, morphine, methadone, codeine, etc.)| \n <*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 \nor financial problems?| | 4a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4008*>| 4b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4009*>| 4c. Cannabis \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | ASSIST Scores:| Tobacco: <-Tobacco->| Alcohol: <-Alcohol->| Cannabis: <-Cannabis->| \n(marijuana, pot, grass, hash, etc.)| <*Answer_4010*>| 4d. Cocaine (coke, crack, etc.)| <*Answer_4011*>| 4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| \n<*Answer_4012*>| 4f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4013*>| 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4014*>| 4h. \nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4017*>| 4i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4018*>| 4j. Other (as specified previously)| \n <*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| \n <*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.)| \n <*Answer_4025*>| 5e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4026*>| 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4027*>| 5g. \nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4028*>| 5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4029*>| 5i. Opioids (heroin, morphine, \nmethadone, 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 \nDRUG, SECOND DRUG, ETC.)?| | 6a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4032*>| 6b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4034*>| 6c. \nCannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4044*>| 6d. Cocaine (coke, crack, etc.)| <*Answer_4045*>| 6e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| \nCocaine: <-Cocaine->| Amphetamine: <-Amphetamine->| Inhalants: <-Inhalants->| Sedatives: <-Sedatives->| Hallucingens: <-Hallucingens->| Opioids: <-Opioids->| Other: <-Other->| | \n<*Answer_4046*>| 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4047*>| 6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4048*>| 6h. \nHallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4049*>| 6i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4050*>| 6j. Other (as previously specified)| \n <*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.)| \n<*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.)| \n<*Answer_4055*>| 7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4086*>| 7f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4087*>| 7g. \nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4088*>| 7h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_4089*>| 7i. Opioids (heroin, morphine, \nmethadone, 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*>| \n8a. 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. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n0-3 Low risk for health and other problems| 4-26 Moderate risk for health and other problems| 27+ High risk of experiencing severe problems and likely to be dependent. | | | Questions and \nAnswers| | 1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY)| | 1a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3934*>| 1b. \nAlcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3935*>| 1c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3936*>| 1d. Cocaine (coke, crack, etc.)| <*Answer_3937*>| 1e. \nAmphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3945*>| 1f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3956*>| 1g. Sedatives or Sleeping Pills \n(Valium, Serepax, Rohypnol, etc.)| <*Answer_3957*>| 1h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_3958*>| 1i. Opioids (heroin, morphine, methadone, codeine, etc.)| \n <*Answer_3960*>| 1j. Other| <*Answer_3961*>| Specify:| <*Answer_3964*>| | 2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, \n
\n\n"], ["113", "BARTHEL INDEX\n", "\n.| .| Barthel Index of Activities of Daily Living| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Barthel Index: <-Index->| The higher the score, the greater the degree of independence, range 0 to 100.| | Questions \nand Answers| | 1. Bowels (preceding week):| <*Answer_5673*>| 2. Bladder (preceding week):| <*Answer_5674*>| 3. Grooming (preceding 24 - 48 hours):| <*Answer_5675*>| 4. Toilet use:| \n <*Answer_5676*>| 5. Feeding:| <*Answer_5677*>| 6. Transfer:| <*Answer_5678*>| 7. Mobility:| <*Answer_5679*>| 8. Dressing:| <*Answer_5680*>| 9. Stairs:| <*Answer_5681*>| 10. \nBathing:| <*Answer_5682*>| | Copyright (c) 1965, Maryland State Medical Journal| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["114", "BAI\n", "\n.| .| Beck Anxiety Inventory| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <*Answer_999999999999*>| | Copyright (c) 1993 NCS Pearson, Inc. T. Beck. \nReproduced, adapted and translated with permission of Publisher NCS Pearson, Inc. All rights reserved.| | Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["115", "BDI\n", "\n.| .| Beck Depression Inventory| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | | BDI Total| DEPRESSION SCORE: <-DEPRESSION SCORE->| 1 <*Answer_348*>| 2 <*Answer_349*>| 3 \n<*Answer_350*>| 4 <*Answer_351*>| 5 <*Answer_352*>| 6 <*Answer_353*>| 7 <*Answer_354*>| 8 <*Answer_355*>| 9 <*Answer_356*>| 10 <*Answer_357*>| 11 <*Answer_358*>| 12 <*Answer_359*>| 13 <*Answer_360*>| \n14 <*Answer_361*>| 15 <*Answer_362*>| 16 <*Answer_363*>| 17 <*Answer_364*>| 18 <*Answer_365*>| 19 <*Answer_366*>| 20 <*Answer_367*>| 21 <*Answer_368*>| 22 <*Answer_369*>| | | Information contained in \nthis 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 \ndiagnostic activities and procedures.| $~\n
\n\n"], ["116", "BDI2\n", "\n.| .| Beck Depression Inventory--Second Edition| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | <*Answer_999999999999*>| <*Answer_7771*>| <*Answer_7772*>| \n <*Answer_7773*>| <*Answer_7774*>| <*Answer_7775*>| <*Answer_7776*>| <*Answer_7777*>| <*Answer_7778*>| <*Answer_7779*>|\n <*Answer_7780*>| <*Answer_7781*>| <*Answer_7782*>| <*Answer_7783*>| <*Answer_7784*>| <*Answer_7785*>|\n <*Answer_7786*>| <*Answer_7787*>| <*Answer_7921*>| <*Answer_7922*>| <*Answer_7923*>| <*Answer_7924*>|\n| Second Edition (BDI-II). Copyright (c) 1996 Aaron T. Beck. Reproduced, adapted and translated with permission of Publisher NCS Pearson, Inc. All rights reserved.| | Information contained in this note \nis 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 \nactivities and procedures.| $~\n
\n\n"], ["117", "BHS\n", "\n.| .| Beck Hopelessness Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <*Answer_999999999999*>| | | Copyright (c) 2001 Aaron T. Beck. Reproduced, adapted and translated with permission of \nPublisher NCR Pearson, Inc. All rights reserved.| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures. $~\n
\n\n"], ["118", "BSI18\n", "\n.| .| Brief Symptom Inventory 18| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | | Community Norms| Somatization: <-Somatization->| Depression: <-Depression->| Anxiety: \n<-Anxiety->| Global Severity Index: <-Global Severity Index->| Oncology Norms| Somatization (oncology): <-Somatization (oncology)->| Depression (oncology): <-Depression (oncology)->| \nAnxiety (oncology): <-Anxiety (oncology)->| Global Severity Index (oncology): <-Global Severity Index (oncology)->| 1 <*Answer_450*>| 2 <*Answer_451*>| 3 <*Answer_452*>| 4 <*Answer_453*>| 5 \n<*Answer_454*>| 6 <*Answer_455*>| 7 <*Answer_456*>| 8 <*Answer_457*>| 9 <*Answer_458*>| 10 <*Answer_459*>| 11 <*Answer_460*>| 12 <*Answer_461*>| 13 <*Answer_462*>| 14 <*Answer_463*>| 15 \n<*Answer_464*>| 16 <*Answer_465*>| 17 <*Answer_466*>| 18 <*Answer_467*>| | Copyright (c) 2000, 2001 LEONARD R. DEROGATIS, PhD.| | Information contained in this note is based on a self-report \nassessment 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.| $~\n
\n\n"], ["119", "BSI18\n", "\n.| .| Brief Symptom Inventory 18| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | Community Norms| Somatization: <-Somatization->| Depression: <-Depression->| Anxiety: \n<-Anxiety->| Global Severity Index: <-Global Severity Index->| | Oncology Norms| Somatization (oncology): <-Somatization (oncology)->| Depression (oncology): <-Depression (oncology)->| \nAnxiety (oncology): <-Anxiety (oncology)->| Global Severity Index (oncology): <-Global Severity Index (oncology)->| | 1 <*Answer_450*>| 2 <*Answer_451*>| 3 <*Answer_452*>| 4 <*Answer_453*>| 5 \n<*Answer_454*>| 6 <*Answer_455*>| 7 <*Answer_456*>| 8 <*Answer_457*>| 9 <*Answer_458*>| 10 <*Answer_459*>| 11 <*Answer_460*>| 12 <*Answer_461*>| 13 <*Answer_462*>| 14 <*Answer_463*>| 15 \n<*Answer_464*>| 16 <*Answer_465*>| 17 <*Answer_466*>| 18 <*Answer_467*>| | Copyright (c) 2000, 2001 LEONARD R. DEROGATIS, PhD.| | Information contained in this note is based on a self-report \nassessment 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.| $~\n
\n\n"], ["12", "SLUMS\n", "\n.|.|The Saint Louis University Mental Status Examination||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \nresults should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.||Copyright (c) 2003 Saint Louis University| $~\n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||SLUMS Score: <-Total Score->||High school education | 27-30 Normal| 21-26 Mild \nNeurocognitive Disorder| 1-20 Dementia ||Less than High School| 25-30 Normal| 20-24 Mild Neurocognitive Disorder| 1-19 Dementia|||Questions and Answers||A. Is the patient alert?| \n<*Answer_4940*>|B. Level of education:| <*Answer_4951*>|1. What day of the week is it?| <*Answer_5083*>|2. What is the year?| <*Answer_5092*>|3. What state are we in?| <*Answer_5093*>|4. \nPlease remember these five objects. I will ask you what they are later. Apple Pen Tie House Car| <*Answer_5338*>|5A. How much did you spend?| <*Answer_5094*>|5B. How much do you have left?| \n<*Answer_5095*>|6. Please name as many animals as you can in one minute.| <*Answer_5096*>|7. What were the five objects I asked you to remember?| <*Answer_5097*>|8A. 87| <*Answer_5098*>|8B. \n649| <*Answer_5099*>|8C. 8537| <*Answer_5100*>|9A. Hour markers:| <*Answer_5101*>|9B. Time:| <*Answer_5102*>|10A. Please place an X in the triangle.| <*Answer_5103*>|10B. Which figure \nis the largest?| <*Answer_5104*>|11A. What was the female's name?| <*Answer_5105*>|11B. What work did she do?| <*Answer_5106*>|11C. When did she go back to work?| <*Answer_5107*>|11D. \nWhat state did she live in?| <*Answer_5108*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment \n
\n\n"], ["120", "BSS\n", "\n.| .| Beck Scale for Suicide Ideation| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <*Answer_999999999999*>| \n | Copyright (c) 2001 Aaron T. Beck. Reproduced, adapted and translated with permission of Publisher NCS Pearson, Inc. All rights reserved.| | Information contained in this note is \nbased 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 \nactivities and procedures.| $~\n
\n\n"], ["121", "BRS\n", "\n.| .| Brief Resiliency Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Brief Resiliency Scale Score: <-BRS->| | | Please make a check mark in the appropriate box to indicate when you are \nfilling out this form:| <*Answer_6022*>| | Questions and Answers:| | 1. I tend to bounce back quickly after hard times.| <*Answer_6023*>| 2. I have a hard time making it through stressful \nevents.| <*Answer_6025*>| 3. It does not take me long to recover from a stressful event.| <*Answer_6401*>| 4. It is hard for me to snap back when something bad happens.| <*Answer_6402*>| \n5. I usually come through difficult times with little trouble.| <*Answer_6403*>| 6. I tend to take a long time to get over setbacks in my life.| <*Answer_6404*>| | | Information contained in \nthis 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 \ndiagnostic activities and procedures.| $~\n
\n\n"], ["122", "CEMI\n", "\n.| .| Client Evaluation of Motivational Interviewing| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n<*Answer_7333*>| 15. Help you feel confident in your ability to change your behavior.| <*Answer_7334*>| 16. Help you recognize the need to change your behavior.| <*Answer_7335*>| | | \nInformation 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 \nconjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Technical Factor: <-Technical Factor->| Relationship \nFactor: <-Relationship Factor->| | CEMI Total: <*Answer_7772*>| | | Scores range from6-64 with higher scores being more motivational Interviewing (MI)consistent| | \nQuestions and Answers| | 1. Focus on your weakness.| <*Answer_6405*>| 2. Help you to talk about changing your \nbehavior.| <*Answer_6406*>| 3. Act as a partner in your behavior change.| <*Answer_6407*>| 4. Help you to discuss your need to change your behavior.| <*Answer_6408*>| 5. Make you \nfeel distrustful of him/her.| <*Answer_6409*>| 6. Help you examine the pros and cons of changing your behavior.| <*Answer_6410*>| 7. Help you to feel hopeful about changing your \nbehavior.| <*Answer_6411*>| 8. Argue with you to change your behavior.| <*Answer_6412*>| 9. Change the topic when you become upset about changing your behavior.| <*Answer_6413*>| \n10. Push you forward when you become unwilling to talk about an issue further.| <*Answer_6477*>| 11. Act as an authority on your life.| <*Answer_6478*>| 12. Tell you what to do.| \n<*Answer_6479*>| 13. Argue with you about needing to be 100% ready to change your behavior.| <*Answer_7332*>| 14. Show you that she/he believes in your ability to change your behavior.| \n
\n\n"], ["123", "SNQ\n", "\n.| .| Sleep Need Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \n DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | To determine what the next week's Total In Bed (TIB) should be, first calculate sleep efficiency (SE).| \n| If SE is greater than or equal to 85% -- modify TIB according to the following scores on the Sleep Need Questionnaire:| (a) Score 9 or less - no change in TIB| (b) Score 10 to 12 - TIB is increased by 15 \nminutes for that week (and another 15 minutes for the following week, if you see the patient biweekly).| (c) Score 13 or more - TIB is increased by 30 minutes for that week (and another 30 \nminutes the following week, if you see the patient biweekly).| | If SE < 80% -- reduce TIB but only if the score on the Sleep Need Questionnaire: is 9 or less.| | Otherwise do not change TIB| \n | | Sleep Need Questionnaire Score: <-SNQ->| | | Questions and Answers| | 1. Did you feel tired or fatigued during the day or evening?| <*Answer_6480*>| 2. Were you sleepy or \ndrowsy during the day or evening?| <*Answer_6481*>| 3. Did you take any naps or fall asleep briefly during the day or evening?| <*Answer_6482*>| 4. Did you feel you had been getting \nan adequate amount of sleep?| <*Answer_6483*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["124", "IMRA\n", "\n.| .| Illness Management and Recovery Assessment for Behavioral Family Therapy| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \nthe way of your doing things that you would like to do or need to do?| <*Answer_6805*>| 8. Relapse Prevention Planning: Which of the following would best describe what you know and have done in \norder to not have a relapse?| <*Answer_6806*>| 9. Relapse of symptoms: When is the last time you had a relapse of symptoms (that is, when symptoms have gotten much worse)?| <*Answer_6807*>| \n10. Psychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons?| <*Answer_6808*>| 11. Coping: How well do you feel that you are \ncoping with your mental or emotional illness from day to day?| <*Answer_6809*>| 12. Involvement with self-help activities: How involved are you in consumer run services, peer support groups, \nAlcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other similar self-help programs? | <*Answer_6810*>| 13. Using medication effectively: How often do you take your \nmedication as prescribed?| <*Answer_6811*>| 14. Functioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships; to money, housing, \nand legal concerns; to difficulty showing up at appointments or paying attention during them; or to increased symptoms. Over the past 3 months, how much did drinking get in the way of your \nfunctioning? | <*Answer_6812*>| 15. Functioning affected by drug use. Using street drugs and misusing prescription or over-the-counter medication can interfere with functioning when it \ncontributes to conflict in relationships; to money, housing, and legal concerns; to difficulty showing up at appointments or paying attention during them; or to increased symptoms. Over the past 3 \nmonths, how much did drug use get in the way of your functioning? | <*Answer_6813*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Total IMRA Score: <-IMRA->| | High scores indicate \nalone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nmore recovery and illness management skills.| | Please indicate what stage of therapy you are at present| <*Answer_6798*>| | Questions and Answers| | 1. Progress toward goals: In the \npast 3 months, you have come up with...| <*Answer_6799*>| 2. Knowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication?| \n<*Answer_6800*>| 3. Involvement of family and friends in my mental health treatment: How much are family members, friends, boyfriends or girlfriends, and other people who are important to you \n(outside the mental health agency) involved in your treatment? | <*Answer_6801*>| 4. Contact with people outside of your family: In a normal week, how many times do you talk to someone outside \nof your family (a friend, co-worker, classmate, roommate, etc.)?| <*Answer_6802*>| 5. Time in structured roles: How much time do you spend working, volunteering, being a student, being a parent, \ntaking care of someone else or someone else's house or apartment? That is, how much time do you spend doing activities that are expected of you for or with another person? (This would not include \nself-care or personal home maintenance.) | <*Answer_6803*>| 6. Symptom distress: How much do symptoms bother you?| <*Answer_6804*>| 7. Impairment of functioning: How much do symptoms get in \n
\n\n"], ["125", "CSI\n", "\n.| .| Couple Satisfaction Index| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nconjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | CSI Score: <-CSI->| | | Questions and Answers| | 1. Please indicate the degree of happiness, all things considered,\n of your relationship.| <*Answer_6484*>| 2. In general, how often do you think that things between you and your partner are going well?| <*Answer_6485*>| 3. Our relationship is strong.| \n<*Answer_6486*>| 4. My relationship with my partner makes me happy.| <*Answer_6487*>| 5. I have a warm and comfortable relationship with my partner.| <*Answer_6488*>| 6. I really feel like \npart of a team with my partner.| <*Answer_6491*>| 7. How rewarding is your relationship with your partner?| <*Answer_6492*>| 8. How well does your partner meet your needs?| \n<*Answer_6494*>| 9. To what extent has your relationship met your original expectations?| <*Answer_6497*>| 10. In general, how satisfied are you with your relationship?| <*Answer_6559*>| 11. \nMy relationship is boring vs. interesting:| <*Answer_6732*>| 12. My relationship is bad vs. good:| <*Answer_6733*>| 13. My relationship is empty vs. full:| <*Answer_6734*>| 14. My \nrelationship is fragile vs. sturdy:| <*Answer_6735*>| 15. My relationship is discouraging vs. hopeful:| <*Answer_6736*>| 16. My relationship is miserable vs. enjoyable:| <*Answer_7294*>| \n| | 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 \n
\n\n"], ["126", "FOCI\n", "\n \n \n FOCI Symptom Severity Total Score: <-Part B->| |\n \n Total Scores range from a minimum of 0 to a maximum of 20, with higher scores indicating greater symptom severity.| |\n \n \n Questions and Answers| |\n \n Part A:\n Have you been bothered by unpleasant thoughts or images that repeatedly enter your mind, such as:| |\n|\n 1. Concerns with contamination (dirt, germs, chemicals, radiation) or acquiring a serious illness such as AIDS?|\n <*Answer_6814*>|\n 2. Overconcern with keeping objects (clothing, tools, etc) in perfect order or arranged exactly?|\n <*Answer_6815*>|\n 3. Images of death or other horrible events?|\n <*Answer_6816*>|\n 4. Personally unacceptable religious or sexual thoughts?|\n <*Answer_6817*>| |\n \n Have you worried a lot about terrible things happening, such as:| |\n .| Florida Obsessive Compulsive Inventory (FOCI)|\n \n 5. Fire, burglary or flooding of the house?|\n <*Answer_6818*>|\n 6. Accidentally hitting a pedestrian with your car or letting it roll down a hill?|\n <*Answer_6819*>|\n 7. Spreading an illness (giving someone AIDS)?|\n <*Answer_6820*>|\n 8. Losing something valuable?|\n <*Answer_6821*>|\n 9. Harm coming to a loved one because you weren't careful enough?|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:\n <*Answer_6822*>| |\n \n Have you worried about acting on an unwanted and senseless urge or impulse, such as:| |\n 10. Physically harming a loved one, pushing a stranger in front of a bus, steering your car into oncoming traffic;|\n inappropriate sexual contact; or poisoning dinner guests?|\n <*Answer_6823*>| |\n \n Have you felt driven to perform certain acts over and over again, such as:| |\n 11. Excessive or ritualized washing, cleaning or grooming?|\n <*Answer_6824*>|\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |\n 12. Checking light switches, water faucets, the stove, door locks or the emergency brake?|\n <*Answer_6825*>|\n 13. Counting, arranging; evening-up behaviors (making sure socks are at same height)?|\n <*Answer_6826*>|\n 14. Collecting useless objects or inspecting the garbage before it is thrown out?|\n <*Answer_6827*>|\n 15. Repeating routine actions (in/out of chair, going through doorway, relighting cigarette) a certain number of times|\n or until it feels just right?|\n <*Answer_6828*>|\n 16. Needing to touch objects or people?|\n \n <*Answer_6829*>|\n 17. Unnecessary rereading or rewriting; reopening envelopes before they are mailed?|\n <*Answer_6830*>|\n 18. Examining your body for signs of illness?|\n <*Answer_6831*>|\n 19. Avoiding colors ("red" means blood), numbers ("13" is unlucky) or names (those that start with "D" signify death) |\n that are associated with dreaded events or unpleasant thoughts?|\n <*Answer_6832*>|\n 20. Needing to "confess" or repeatedly asking for reassurance that you said or did something correctly?|\n <*Answer_6833*>| |\n FOCI Symptom Checklist Total Score: <-Part A->| |\n \n PART B: In the past month...|\n \n 1. On average, how much time is occupied by these thoughts or behaviors each day?|\n <*Answer_6834*>|\n 2. How much distress do they cause you?|\n <*Answer_6835*>|\n 3. How hard is it for you to control them?|\n <*Answer_6836*>|\n 4. How much do they cause you to avoid doing anything, going anyplace or being with anyone?|\n \n <*Answer_6837*>|\n 5. How much do they interfere with school work or your social or family life?|\n <*Answer_6838*>| | |\n 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.\n| $~\n Total Scores range from a minimum of 0 to a maximum of 20, with higher scores indicating greater symptomatology.| |\n\n\n"], ["127", "PCL-5\n", "\n PCL-5\n| Gender: <.Patient_Gender.>\n| \n| \n| PCL-5 Score: <-PCL-5->\n| \n| This measure assesses an individual's perception of the distress associated\n| with possible PTSD symptoms. It is not used to diagnose PTSD. Symptoms are\n| rated from 0-4 in terms of distress they cause the individual. Scores that\n| are greater than or equal to 31-33 suggest that the veteran may meet the\n| criteria for a PTSD diagnosis. However, it is important to use caution when\n| \n| using this cutoff since it is possible for some Veterans with scores lower\n| than 31-33 to meet criteria for PTSD. \n| \n| Additional testing using a structured diagnostic interview, such as the\n| Clinician Administered PTSD Scale for DSM-5, is recommended to confirm\n| diagnostic status.\n|\n| Values range from 0 to 80 with higher scores indicating more probable PTSD.\n| \n| \n| Date Given: <.Date_Given.>\n| Questions and Answers: \n| \n| 1. Repeated, disturbing, and unwanted memories of the stressful experience?\n| <*Answer_6841*>\n| 2. Repeated, disturbing dreams of the stressful experience?\n| <*Answer_6842*>\n| 3. Suddenly feeling or acting as if the stressful experience were actually\n| happening again (as if you were actually back there reliving it)?\n| <*Answer_6843*>\n| 4. Feeling very upset when something reminded you of the stressful \n| Clinician: <.Staff_Ordered_By.>\n| experience?\n| <*Answer_6844*>\n| 5. Having strong physical reactions when something reminded you of the\n| stressful experience (for example, heart pounding, trouble breathing,\n| sweating)?\n| <*Answer_6845*>\n| 6. Avoiding memories, thoughts, or feelings related to the stressful \n| experience?\n| <*Answer_6846*>\n| 7. Avoiding external reminders of the stressful experience (for example, \n| Location: <.Location.>\n| people, places, conversations, activities, objects, or situations)?\n| <*Answer_6847*>\n| 8. Trouble remembering important parts of the stressful experience?\n| <*Answer_6848*>\n| 9. Having strong negative beliefs about yourself, other people, or the\n| world (for example, having thoughts such as: I am bad, there is \n| something seriously wrong with me, no one can be trusted, the world is\n| completely dangerous)?\n| <*Answer_6849*>\n| 10. Blaming yourself or someone else for the stressful experience or what\n| \n| happened after it?\n| <*Answer_6850*>\n| 11. Having strong negative feelings such as fear, horror, anger, guilt, or\n| shame?\n| <*Answer_6851*>\n| 12. Loss of interest in activities that you used to enjoy?\n| <*Answer_6852*>\n| 13. Feeling distant or cut off from other people?\n| <*Answer_6853*>\n| 14. Trouble experiencing positive feelings (for example, being unable to\n| Veteran: <.Patient_Name_Last_First.>\n| feel happiness or have loving feelings for people close to you)?\n| <*Answer_6854*>\n| 15. Irritable behavior, angry outbursts, or acting aggressively?\n| <*Answer_6855*>\n| 16. Taking too many risks or doing things that could cause you harm?\n| <*Answer_6856*>\n| 17. Being "superalert" or watchful or on guard?\n| <*Answer_6857*>\n| 18. Feeling jumpy or easily startled?\n| <*Answer_6858*>\n| SSN: <.Patient_SSN.>\n| 19. Having difficulty concentrating?\n| <*Answer_6859*>\n| 20. Trouble falling or staying asleep?\n| <*Answer_6860*>\n| \n| Information contained in this note is based on a self-report assessment and is not sufficient\n to use alone for diagnostic purposes. Assessment results should be verified for accuracy and\n used in conjunction with other diagnostic activities and procedures.\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["128", "SST-VOI\n", "\n.| .| SST - Veteran Outcome Survey ( Initial)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. How satisfied are you with the quality of your relationships with \nfriends, family, and the other people in your life?| <*Answer_6861*>| 2. How skilled are you at communicating with other people in your life?| <*Answer_6862*>| 3. How satisfied are you with \nyour involvement in community activities? Community activities include working, volunteering, being a student, or attending clubs and organizations.| <*Answer_6863*>| 4. How skilled are you at \ninteracting with others in community settings? Community settings include a work or volunteer job site, school, or clubs and organizations.| <*Answer_6864*>| 5. How satisfied are you with your \nrelationships with the people who provide your mental health services?| <*Answer_6865*>| 6. How skilled are you at interacting with your mental health service providers?| <*Answer_6866*>| 7. \nHow would you rate your attendance for scheduled mental health appointments?| <*Answer_6867*>| 8. How satisfied are you with your overall health and well-being?| <*Answer_6868*>| 9. How \nskilled are you at managing your overall health and well-being?| <*Answer_6869*>| To be completed by the clinician at the end of the individual session:||What is the main goal that the Veteran \nwould like to reach with the help of Social Skills Training?| <*Answer_6870*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \n
\n\n"], ["129", "SST-VOI\n", "\n.| .| Social Skills Training - Veteran Outcome Survey| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | SST-VOI| Satisfaction Score: <-Satisfaction->| Skill Score: <-Skill->| | \n| Questions and Answers| | 1. How satisfied are you with the quality of your relationships with friends, family, and the other people in your life?| <*Answer_6861*>| 2. How skilled are you at \ncommunicating with other people in your life?| <*Answer_6862*>| 3. How satisfied are you with your involvement in community activities? Community activities include working, volunteering, being a \nstudent, or attending clubs and organizations.| <*Answer_6863*>| 4. How skilled are you at interacting with others in community settings? Community settings include a work or volunteer job site, \nschool, or clubs and organizations.| <*Answer_6864*>| 5. How satisfied are you with your relationships with the people who provide your mental health services?| <*Answer_6865*>| 6. How \nskilled are you at interacting with your mental health service providers?| <*Answer_6866*>| 7. How would you rate your attendance for scheduled mental health appointments?| <*Answer_6867*>| \n8. How satisfied are you with your overall health and well-being?| <*Answer_6868*>| 9. How skilled are you at managing your overall health and well-being?| <*Answer_6869*>| | What is the main \ngoal that the Veteran would like to reach with the help of Social Skills Training?| <*Answer_6870*>| | | Information contained in this note is based on a self-report assessment and is not \n
\n\n"], ["13", "GAD-7\n", "\n.|.|Generalized Anxiety Disorder, 7 items||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |GAD-7 score: <-Anxiety->||A low score indicates the absence of anxiety, a high score indicates |the presence of anxiety \nsymptoms; the range is 0 to 21. A score of 15 |or greater is considered clinically significant, meriting active |treatment for anxiety. A score of 10 to 14 indicates a condition that |should be \ncarefully evaluated.||Questions and Answers||1. Feeling nervous, anxious or on edge| <*Answer_5109*>|2. Not being able to stop or control worrying| <*Answer_5110*>|3. Worrying too much about \ndifferent things| <*Answer_5111*>|4. Trouble relaxing| <*Answer_5112*>|5. Being so restless that it is hard to sit still| <*Answer_5113*>|6. Becoming easily annoyed or irritable| \n<*Answer_5114*>|7. Feeling afraid as if something awful might happen| <*Answer_5115*>||Information contained in this note is based on a self-report assessment and is not sufficient to use alone \nfor diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["130", "SST-VOF\n", "\n.| .| SST - Veteran Outcome Survey ( Final )| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<*Answer_6882*>| 12. How helpful was Social Skills Training in improving your communication with friends, family, and the other people in your life?| <*Answer_6883*>| 13. How helpful was Social \nSkills Training in improving your interactions with others in community settings?| <*Answer_6884*>| 14. How helpful was Social Skills Training in improving your communication with mental health \nservice providers?| <*Answer_6885*>| 15. How helpful was Social Skills Training in improving your overall health and well-being?| <*Answer_6886*>| | | Information contained in this note is \nbased 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 \nactivities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. How satisfied are you with the quality of your relationships with friends, \nfamily, and the other people in your life?| <*Answer_6871*>| 2. How skilled are you at communicating with other people in your life?| <*Answer_6872*>| 3. How satisfied are you with your \ninvolvement in communtiy activities, which include working, volunteering, being a student, or attending clubs and organizations?| <*Answer_6873*>| 4. How skilled are you at interacting with \nothers in community settings? Community settings include a work or volunteer job site, school, or clubs and organizations.| <*Answer_6874*>| 5. How satisfied are you with your relationships with \nthe people who provide your mental health services?| <*Answer_6875*>| 6. How skilled are you at interacting with your mental health service providers?| <*Answer_6876*>| 7. How would you rate \nyour attendance for scheduled mental health appointments?| <*Answer_6877*>| 8. How satisfied are you with your overall health and well-being?| <*Answer_6878*>| 9. How skilled are you at \nmanaging your overall health and well-being?| <*Answer_6879*>| This is the main goal that you chose before you started attending Social Skills Training?| <*Answer_6880*>| 10. Please rate your \nprogress towards the recovery goal you identified at the start of Social Skills Training.| <*Answer_6881*>| 11. How helpful was Social Skills Training in reaching your recovery goal?| \n
\n\n"], ["131", "SOCRATES 8A\n", "\n.| .| Stages of Change Readiness and Treatment Eagerness Scale - 8A| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | \nproblem drinker.| <*Answer_6893*>| 8. I'm not just thinking about changing my drinking, I'm already doing something about it.| <*Answer_6894*>| 9. I have already changed \nmy drinking, and I am looking for ways to keep from slipping| back to my old pattern.| <*Answer_6895*>| 10. I have serious problems with drinking.| <*Answer_6896*>| \n11. Sometimes I wonder if I am in control of my drinking.| <*Answer_6897*>| 12. My drinking is causing a lot of harm.| <*Answer_6898*>| 13. I am actively doing things now \nto cut down or stop drinking.| <*Answer_6899*>| 14. I want help to keep from going back to the drinking problems that I had before.| <*Answer_6900*>| 15. I know that I \nhave a drinking problem.| <*Answer_6901*>| 16. There are times when I wonder if I drink too much.| <*Answer_6902*>| 17. I am an alcoholic.| <*Answer_6903*>| \n18. I am working hard to change my drinking.| <*Answer_6904*>| 19. I have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink.| \n <*Answer_6905*>| | | 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 \nbe verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nVeteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Guide for interpreting \nSOCRATES scores:| | RAW SCORES| Indicator DECILE Recognition Ambivalence Taking Steps| Score Score Score Score | \n| Very High 90 19-20 39-40 | 80 18 37-38| High 70 35 17 36| \n60 34 16 34-35| Medium 50 32-33 15 33| 40 31 14 31-32| Low 30 29-30 \n 12-13 30| 20 27-28 9-11 26-29| Very Low 10 7-26 4-8 8-25| | <.DLL_String.> | | Questions and \nAnswers| | 1. I really want to make changes in my drinking.| <*Answer_6887*>| 2. Sometimes I wonder if I am an alcoholic.| <*Answer_6888*>| 3. If I don't change \nmy drinking soon, my problems are going to get worse.| <*Answer_6889*>| 4. I have already started making some changes in my drinking.| <*Answer_6890*>| 5. I was drinking \ntoo much at one time, but I've managed to change my drinking.| <*Answer_6891*>| 6. Sometimes I wonder if my drinking is hurting other people.| <*Answer_6892*>| 7. I am a \n
\n\n"], ["132", "SOCRATES 8D\n", "\n.| .| Stages of Change Readiness and Treatment Eagerness Scale - 8D| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | \n 7. I am a problem a drug problem.| <*Answer_6912*>| 8. I'm not just thinking about changing my drug use, I'm already doing something about it.| <*Answer_6913*>| 9. I \nhave already changed my drug use, and I am looking for ways to keep from slipping| back to my old pattern.| <*Answer_6914*>| 10. I have serious problems with drugs.| \n<*Answer_6915*>| 11. Sometimes I wonder if I am in control of my drug use.| <*Answer_6916*>| 12. My drug use is causing a lot of harm.| <*Answer_6917*>| 13. I am \nactively doing things now to cut down or stop my use of drugs.| <*Answer_6918*>| 14. I want help to keep from going back to the drug problems that I had before.| \n<*Answer_6919*>| 15. I know that I have a drug problem.| <*Answer_6920*>| 16. There are times when I wonder if I use drugs too much.| <*Answer_6921*>| 17. I am an \ndrug addict.| <*Answer_6922*>| 18. I am working hard to change my drug use.| <*Answer_6923*>| 19. I have made some changes in my drug use, and I want some help to keep \nfrom going back to the way I used before.| <*Answer_6924*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nVeteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Guide for interpreting \nSOCRATES scores:| | RAW SCORES| Indicator DECILE Recognition Ambivalence Taking Steps| Score Score Score Score | \n | Very High 90 19-20 39-40 | 80 18 37-38| High 70 35 17 36| \n 60 34 16 34-35| Medium 50 32-33 15 33| 40 31 14 31-32| Low 30 \n29-30 12-13 30| 20 27-28 9-11 26-29| Very Low 10 7-26 4-8 8-25| | <.DLL_String.>| | \nQuestions and Answers| | 1. I really want to make changes in my use of drugs.| <*Answer_6906*>| 2. Sometimes I wonder if I am an addict.| <*Answer_6907*>| 3. If \nI don't change my drug use soon, my problems are going to get worse.| <*Answer_6908*>| 4. I have already started making some changes in my use of drugs.| <*Answer_6909*>| \n5. I was using drugs too much at one time, but I've managed to change that.| <*Answer_6910*>| 6. Sometimes I wonder if my drug use is hurting other people.| <*Answer_6911*>| \n
\n\n"], ["133", "ASSIST-NIDA\n", "\n.| .| Alcohol Smoking and Substance Involvement Screening - NIDA modified version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \nSedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)| <*Answer_6934*>| 1g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)| \n<*Answer_6935*>| 1h. Street opioids (heroin, opium, etc.)| <*Answer_6936*>| 1i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, \netc.)?| <*Answer_6937*>| 1j. Other| <*Answer_7174*>| Specify:| <*Answer_7175*>| 2a. In the past three months, how often have you used cannabis (marijuana, pot, grass, hash, etc.)?| \n<*Answer_6939*>| 2b. In the past three months, how often have you used cocaine (coke, crack, etc.)?| <*Answer_6940*>| 2c. In the past three months, how often have you used prescription stimulants \n(Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6941*>| 2d. In the past three months, how often have you used methamphetamine (speed, crystal meth, etc.)?| <*Answer_6942*>| 2e. In \nthe past three months, how often have you used inhalants (nitrous oxide, gas, paint thinner, etc.)?| <*Answer_6943*>| 2f. In the past three months, how often have you used sedatives or sleeping \npills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?| <*Answer_6944*>| 2g. In the past three months, how often have you used hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| \n<*Answer_6945*>| 2h. In the past three months, how often have you used street opioids (heroin, opium, etc.)?| <*Answer_6946*>| 2i. In the past three months, how often have you used prescription \nopioids (fentanyl, oxycodone, [OxyContin], hydrocodone [Vicodin],methadone, buprenorphine, etc.)?| <*Answer_6947*>| 2j. In the past three months, how often have you used other substances (as \nspecified above)?| <*Answer_7167*>| 3a. In the past 3 months, how often have you had a strong desire or urge to use cannabis (marijuana, pot, grass, hash, etc.)?| <*Answer_6949*>| 3b. In the \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | ASSIST NIDA| Cannabis: <-Cannabis->| \npast 3 months, how often have you had a strong desire or urge to use cocaine (coke, crack, etc.)?| <*Answer_6950*>| 3c. In the past 3 months, how often have you had a strong desire or urge to use \nprescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6951*>| 3d. In the past 3 months, how often have you had a strong desire or urge to use \nmethamphetamine (speed, crystal meth, etc.)?| <*Answer_6952*>| 3e. In the past 3 months, how often have you had a strong desire or urge to use inhalants (nitrous oxide, gas, paint thinner, etc.)?| \n <*Answer_6953*>| 3f. In the past 3 months, how often have you had a strong desire or urge to use sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?| \n<*Answer_6954*>| 3g. In the past 3 months, how often have you had a strong desire or urge to use hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| <*Answer_6955*>| 3h. In the past 3 \nmonths, how often have you had a strong desire or urge to use street Opioids (heroin, opium, etc.)?| <*Answer_6956*>| 3i. In the past 3 months, how often have you had a strong desire or urge to \nuse prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6957*>| 3j. In the past 3 months, how often have you had a strong desire \nor urge to use other substances (as specified above)?| <*Answer_7169*>| 4a. During the past 3 months, how often has your use of cannabis (marijuana, pot, grass, hash, etc.) led to health, social, \nlegal or financial problems?| <*Answer_6959*>| 4b. During the past 3 months, how often has your use of cocaine (coke, crack, etc.) led to health, social, legal or financial problems?| \n<*Answer_6960*>| 4c. During the past 3 months, how often has your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.) led to health, social, legal or \nCocaine: <-Cocaine->| Prescription stimulants: <-Prescription stimulants->| Methamphetamine: <-Methamphetamine->| Inhalants: <-Inhalants->| Sedatives or \nfinancial problems?| <*Answer_6961*>| 4d. During the past 3 months, how often has your use of methamphetamine (speed, crystal meth, etc.) led to health, social, legal or financial problems?| \n<*Answer_6962*>| 4e. During the past 3 months, how often has your use of inhalants (nitrous oxide, gas, paint thinner, etc.) led to health, social, legal or financial problems?| <*Answer_6963*>| \n4f. During the past 3 months, how often has your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.) led to health, social, legal or financial problems?| \n<*Answer_6964*>| 4g. During the past 3 months, how often has your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.) led to health, social, legal or financial problems?| \n<*Answer_6965*>| 4h. During the past 3 months, how often has your use of street opioids (heroin, opium, etc.) led to health, social, legal or financial problems?| <*Answer_6966*>| 4i. During the \npast 3 months, how often has your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.) led to health, social, legal or financial \nproblems? | <*Answer_6967*>| 4j. During the past 3 months, how often has your use of other substances (as specified above) led to health, social, legal or financial problems?| \n<*Answer_7170*>| 5a. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of cannabis (marijuana, pot, grass, hash, etc.)?| \n<*Answer_6969*>| 5b. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of cocaine (coke, crack, etc.)?| <*Answer_6970*>| 5c. During \nthe past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)? | \nsleeping pills: <-Sedatives or sleeping pills->| Hallucinogens: <-Hallucinogens->| Street Opioids: <-Street Opioids->| Prescription opioids: <-Prescription opioids->| \n <*Answer_6971*>| 5d. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of methamphetamine (speed, crystal meth etc.)?| \n<*Answer_6972*>| 5e. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of inhalants (nitrous oxide, gas, paint thinner, etc.)?| \n<*Answer_6973*>| 5f. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of sedatives or sleeping pills (Valium, Serepax, Ativan, Librium, \nXanax, GHB, etc.)?| <*Answer_6974*>| 5g. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of hallucinogens ( LSD, acid, PCP, Special \nK, ecstasy, etc.)?| <*Answer_7309*>| 5h. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of street Opioids (heroin, opium, etc.)?| \n <*Answer_6976*>| 5i. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of prescribed opioids (fentanyl, oxycodone [OxyContin], \nhydrocodone [Vicodin], methadone, buprenorphine, etc.)? | <*Answer_6977*>| 5j. During the past 3 months, how often have you failed to do what was normally expected of you because of your use of \nother substances (as specified above)?| <*Answer_7171*>| 6a. Has a friend or relative or anyone else ever expressed concern about your use of cannabis (marijuana, pot, grass, hash, etc.)?| \n<*Answer_6979*>| 6b. Has a friend or relative or anyone else ever expressed concern about your use of cocaine (coke, crack, etc.)?| <*Answer_6980*>| 6c. Has a friend or relative or anyone else \never expressed concern about your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6981*>| 6d. Has a friend or relative or anyone else ever \n Other: <-Other->| | | Level of risk associated with different substance involvement score ranges| for illicit or nonmedical prescription drug use:| \nexpressed concern about your use of methamphetamine (speed, crystal meth, etc.)?| <*Answer_6982*>| 6e. Has a friend or relative or anyone else ever expressed concern about your use of inhalants \n(nitrous oxide, gas, paint thinner, etc.)?| <*Answer_6983*>| 6f. Has a friend or relative or anyone else ever expressed concern about your use of sedatives or sleeping pills (Valium, Serepax, \nXanax, Ativan, Librium, GHB, etc.)?| <*Answer_6984*>| 6g. Has a friend or relative or anyone else ever expressed concern about your use of hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| \n <*Answer_6985*>| 6h. Has a friend or relative or anyone else ever expressed concern about your use of street opioids (heroin, opium, etc.)?| <*Answer_6986*>| 6i. Has a friend or relative or \nanyone else ever expressed concern about your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6987*>| 6j. Has a friend \nor relative or anyone else ever expressed concern about your use of other substances (as specified above)?| <*Answer_7172*>| 7a. Have you ever tried and failed to control, cut down or stop using \ncannabis (marijuana, pot, grass, hash, etc.)?| <*Answer_6989*>| 7b. Have you ever tried and failed to control, cut down or stop using cocaine (coke, crack, etc.)?| <*Answer_6990*>| 7c. Have \nyou ever tried and failed to control, cut down or stop using prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)?| <*Answer_6991*>| 7d. Have you ever tried and \nfailed to control, cut down or stop using methamphetamine (speed, crystal meth, etc.)?| <*Answer_6992*>| 7e. Have you ever tried and failed to control, cut down or stop using inhalants (nitrous \noxide, gas, paint thinner, etc.)?| <*Answer_6993*>| 7f. Have you ever tried and failed to control, cut down or stop using sedatives or sleeping pills (Valium, Serepax, Xanax, Ativan, Librium, GHB, \n0 - 3 Lower risk| 4 - 26 Moderate risk| 27+ High risk| | | Questions and Answers| | 1. Alcohol (for men, 5 or more drinks a day or for women, 4 \netc.)?| <*Answer_6994*>| 7g. Have you ever tried and failed to control, cut down or stop using hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| <*Answer_6995*>| 7h. Have you ever \ntried and failed to control, cut down or stop using street opioids (heroin, opium, etc.)?| <*Answer_6996*>| 7i. Have you ever tried and failed to control, cut down or stop using prescribed opioids \n(fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6997*>| 7j. Have you ever tried and failed to control, cut down or stop using other substances \n(as specified above)?| <*Answer_7173*>| 8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)?| <*Answer_6999*>| | | Information contained in this note is based on a self-report \nassessment 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.| $~\nor more drinks a day)| <*Answer_6925*>| 2. Tobacco Products| <*Answer_6926*>| 3. Prescription Drugs for Non-Medical Reasons| <*Answer_6927*>| 4. Illegal Drugs| <*Answer_6928*>| 1a. \nCannabis (marijuana, pot, grass, hash, etc.)| <*Answer_6929*>| 1b. Cocaine (coke, crack, etc.)| <*Answer_6930*>| 1c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet \npills, etc.)| <*Answer_6931*>| 1d. Methamphetamine (speed, crystal meth, ice, etc.)| <*Answer_6932*>| 1e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)| <*Answer_6933*>| 1f. \n
\n\n"], ["134", "BSL-23\n", "\n.| .| Borderline Symptom List 23 - (BSL-23)| |\n Questions and Answers| |\n 1. It was hard for me to concentrate|\n <*Answer_7000*>|\n \n 2. I felt helpless|\n <*Answer_7001*>|\n \n 3. I was absent-minded and unable to remember what I was actually doing|\n <*Answer_7002*>|\n \n Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|\n 4. I felt disgust|\n <*Answer_7003*>|\n \n 5. I thought of hurting myself|\n <*Answer_7004*>|\n \n 6. I didn't trust other people|\n <*Answer_7005*>|\n \n 7. I didn't believe in my right to live|\n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|\n <*Answer_7006*>|\n \n 8. I was lonely|\n <*Answer_7007*>|\n \n 9. I experienced stressful inner tension|\n <*Answer_7008*>|\n \n 10. I had images that I was very much afraid of|\n <*Answer_7009*>|\n SSN: <.Patient_SSN.>| DOB:<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|\n \n 11. I hated myself|\n <*Answer_7010*>|\n \n 12. I wanted to punish myself|\n <*Answer_7011*>| \n \n13. I suffered from shame|\n <*Answer_7012*>|\n \n Gender: <.Patient_Gender.>| |\n 14. My mood rapidly cycled in terms of anxiety, anger, and depression|\n <*Answer_7013*>|\n \n 15. I suffered from voices and noises from inside or outside my head|\n <*Answer_7014*>|\n \n 16. Criticism had a devastating effect on me|\n <*Answer_7015*>|\n \n 17. I felt vulnerable|\n \n <*Answer_7016*>|\n \n 18. The idea of death had a certain fascination for me|\n <*Answer_7017*>|\n \n 19. Everything seemed senseless to me|\n <*Answer_7018*>|\n \n 20. I was afraid of losing control|\n <*Answer_7019*>|\nBSL-23 TOTAL SCORE = <-BSL-23->|\n \n 21. I felt disgusted by myself|\n <*Answer_7020*>|\n \n 22. I felt as if I was far away from myself|\n <*Answer_7021*>|\n \n 23. I felt worthless|\n <*Answer_7022*>| | |\n \n Total scores range from 0-92. Higher scores indicate more borderline symptoms.| |\n 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\n procedures.| $~\n \n
\n\n"], ["135", "D.ERS\n", "\n.| .| Difficulties in Emotion Regulation Scale(DERS)|| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:\n Limited access to emotion regulation strategies(STRATEGIES) = <-STRATEGIES->|\n Lack of emotional awareness (AWARENESS) = <-AWARENESS->|\n Lack of emotional clarity(CLARITY) = <-CLARITY->|\n| \nHigher scores suggest greater problems with emotion regulation.\n|\n|\nQuestions and Answers|\n 1. I am clear about my feelings.| <*Answer_7023*>|\n 2. I pay attention to how I feel.| <*Answer_7024*>|\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| |\n 3. I experience my emotions as overwhelming and out of control.| <*Answer_7025*>|\n 4. I have no idea how I am feeling.| <*Answer_7026*>|\n 5. I have difficulty making sense out of my feelings.| <*Answer_7027*>|\n 6. I am attentive to my feelings.| <*Answer_7028*>|\n 7. I know exactly how I am feeling.| <*Answer_7029*>|\n 8. I care about what I am feeling.| <*Answer_7030*>|\n 9. I am confused about how I feel.| <*Answer_7031*>|\n 10. When I'm upset, I acknowledge my emotions.| <*Answer_7032*>|\n 11. When I'm upset, I become angry with myself for feeling that way.| <*Answer_7033*>|\n 12. When I'm upset, I become embarrassed for feeling that way.| <*Answer_7034*>| 13. When I'm upset, I have difficulty getting work done.| <*Answer_7035*>|\n \n 14. When I'm upset, I become out of control.| <*Answer_7036*>|\n 15. When I'm upset, I believe that I will remain that way for a long time.| <*Answer_7037*>|\n 16. When I'm upset, I believe that I'll end up feeling very depressed.| <*Answer_7038*>|\n 17. When I'm upset, I believe that my feelings are valid and important.| <*Answer_7039*>|\n 18. When I'm upset, I have difficulty focusing on other things.| <*Answer_7040*>|\n 19. When I'm upset, I feel out of control.| <*Answer_7041*>|\n 20. When I'm upset, I can still get things done.| <*Answer_7042*>|\n 21. When I'm upset, I feel ashamed with myself for feeling that way.| <*Answer_7043*>|\n 22. When I'm upset, I know that I can find a way to eventually feel better.| <*Answer_7044*>|\n 23. When I'm upset, I feel like I am weak.| <*Answer_7045*>|\nDERS TOTAL SCORE = <-TOTAL->|\n 24. When I'm upset, I feel like I can remain in control of my behaviors.| <*Answer_7046*>|\n 25. When I'm upset, I feel guilty for feeling that way.| <*Answer_7047*>|\n 26. When I'm upset, I have difficulty concentrating.| <*Answer_7048*>|\n 27. When I'm upset, I have difficulty controlling my behaviors.| <*Answer_7049*>|\n 28. When I'm upset, I believe there is nothing I can do to make myself feel better.| <*Answer_7050*>|\n 29. When I'm upset, I become irritated with myself for feeling that way.| <*Answer_7051*>|\n 30. When I'm upset, I start to feel very bad about myself.| <*Answer_7052*>|\n 31. When I'm upset, I believe that wallowing in it is all I can do.| <*Answer_7053*>|\n 32. When I'm upset, I lose control over my behaviors.| <*Answer_7054*>|\n 33. When I'm upset, I have difficulty thinking about anything else.| <*Answer_7055*>|\n| \n 34. When I'm upset, I take time to figure out what I'm really feeling.| <*Answer_7056*>|\n 35. When I'm upset, it takes me a long time to feel better.| <*Answer_7057*>|\n 36. When I'm upset, my emotions feel overwhelming.| <*Answer_7058*>| | |\n 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.|\n $~\nSUBSCALE SCORES: |\n Non-acceptance of emotional responses(NONACCEPT) = <-NONACCEPT->|\n Difficulties engaging in goal-directed behavior(GOALS) = <-GOALS->|\n Impulse control difficulties(IMPULSE) = <-IMPULSE->|\n
\n\n"], ["136", "KATZ-ADL-6PT\n", "\n.| .| Katz Index of Independence in Activities of Daily Living-6pt | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Katz Index of Independence in ADL: <-KATZ ADL->| | Index score possible range is 0 to 6. A score of 6 indicates full function, 4 indicates moderate impairment,\n and 2 or less indicates severe functional impairment. | |\n| Questions and Answers| | 1. BATHING |\n <*Answer_7059*>| 2. DRESSING | <*Answer_7060*>| 3. \nTOILETING | <*Answer_7061*>| 4. TRANSFER| <*Answer_7062*>| 5. CONTINENCE| \n <*Answer_7063*>| 6. FEEDING| <*Answer_7064*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["137", "YBOCSII\n", "\n.| .| Yale-Brown Obsessive Compulsive Scale - II| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \nthat their obsessions are "disturbing" or "upsetting" but deny "anxiety." Only rate distress that seems generated by obsessions, not generalized anxiety or anxiety associated with other conditions.]| \n | <*Answer_7068*>| | 5. INTERFERENCE FROM OBSESSIONS:| "How much do your obsessive thoughts interfere with your social, school, or work (role) functioning?" [If currently not \nworking (or attending school), determine how much performance would be affected if patient were employed (or in school).] "Have you been avoiding doing anything, going any place, or being with anyone \nbecause of your obsessions?" [Evaluate impact of avoidance on functioning.]| | <*Answer_7069*>| | 6. TIME SPENT ON COMPULSIONS:| "How much time do you spend performing \ncompulsive behaviors?" [When rituals involving activities of daily living are chiefly present, ask:] "How much longer than most people does it take to complete routine activities because of your \nrituals?" [When compulsions occur as brief, intermittent behaviors, it may be difficult to assess time spent performing them in terms of total hours. In such cases, estimate time by determining how \nfrequently they are performed. Consider both the number of times compulsions are performed and how much of the day is affected. When estimating frequency, count separate occurrences of compulsive \nbehaviors, not number of repetitions. In most cases compulsions are observable behaviors (e.g., hand washing or refusing to shake ands), but some compulsions are covert (e.g., silent checking or \npraying); these mental rituals should be rated as you would overt compulsions. "Active avoidance" (e.g., rule governed behaviors that ensure a minimum "safe" distance from contaminated areas or \nwearing a glove on one hand to keep it clean) like compulsions, can manifest as discrete behavioral acts, measurable in hours or by frequency, so should be rated on this item. "Passive avoidance", \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | YBOCS II| \non the other hand, may be difficult to quantify temporally; however, its relationship to compulsions and resultant impact on distress and functioning can be measured on items 9 and 10 respectively.| \n | <*Answer_7070*>| | 7. RESISTANCE TO COMPULSIONS:| "How much of an effort do you make to resist the compulsions?" [Only rate effort made to resist, not success or failure in \nactually controlling the compulsions. How much the patient resists the compulsions may or may not correlate with his ability to control them. Note that this item does not directly measure the \nseverity of the compulsions; rather it rates a manifestation of health, i.e., the effort the patient makes to counteract the compulsions. Thus, the more the patient tries to resist, the less impaired \nis this aspect of his functioning. If the compulsions are minimal, the patient may not feel the need to resist them. In such cases, a rating of "0" should be given.]| | <*Answer_7071*>| \n | 8. CONTROL OVER COMPULSIONS:| "How strong is the drive to perform the compulsions?" [Pause] "How much control do you have over the behaviors?" [In contrast to the preceding item on \nresistance, this item directly measures success or failure in controlling compulsions.]| | <*Answer_7072*>| | 9. DISTRESS IF COMPULSIONS PREVENTED:| "How would you feel if \nprevented from performing your compulsion(s)?" [Pause] "How distressed would you become?" [Rate degree of distress patient would experience if performance of the ritual were prevented or suddenly \ninterrupted without reassurance. Like compulsions, avoidance maneuvers can reduce distress; conversely, forced confrontation with avoided objects can engender distress. Ask similar questions about \navoidance:] "How would you feel if you weren't allowed to avoid?" [In most, but not all cases, performing compulsions reduces anxiety. In other cases, the compulsions themselves can be a source of \nObsession: <-Obsession->| Compulsion: <-Compulsion-> (Note: Questions 11-14 are not included in this total) | Total: <-Total-> | | | Questions and \ndistress when laborious or demanding; they can even be painful as in the case of washing with scalding hot water. In these cases, distress or discomfort produced by the compulsions can be taken into \naccount when rating this item. Apart from these latter instances, this item can be viewed as an indirect measure of how dependent the individual is on compulsions or avoidance to keep distress in \ncheck.]| | <*Answer_7073*>| | 10. INTERFERENCE FROM COMPULSIONS:| "How much do your compulsive behaviors interfere with your social, school, or work (or role) functioning?" [If \ncurrently not working (or attending school), determine how much performance would be affected if patient were employed (or in school).] "Have you been avoiding doing anything, going any place, or \nbeing out of concern you will trigger the compulsions?" [Evaluate impact of avoidance on functioning. An example of avoidance relevant to assessment of compulsions is letting soiled clothes pile up \ninstead of launching into an exhausting and prolonged laundry routine that will defy interruption.]| | <*Answer_7074*>| | 11. INSIGHT:| "Do you think your concerns or behaviors \nare reasonable?" [Pause] "What do you think would happen if you did not perform the compulsion(s)? Are you convinced something would really happen?" [Rate patient's insight into the senselessness or \nexcessiveness of his obsession(s) based on beliefs expressed at the time of the Interview.]| | <*Answer_7075*>| | 12. RELIABILITY:| Rate the overall reliability of the rating \nscores obtained. Factors that may affect reliability include the patient's cooperativeness and his/her natural ability to communicate. The type and severity of obsessive-compulsive symptoms present \nmay interfere with the patient's concentration, attention, or freedom to speak spontaneously (e.g., the content of some obsessions may cause the patient to choose his words very carefully).| \nAnswers| | 1. TIME SPENT ON OBSESSIONS:| "How much of you time is occupied by obsessive thoughts?" [When obsessions occur as brief,intermittent intrusions, it may be difficult to assess \n<*Answer_7310*>| | 13. GLOBAL SEVERITY:| Interviewer's judgment of the overall severity of the patient's illness. Rated from 0 (no illness) to 6 (most severe patient seen). [Consider the \ndegree of distress reported by the patient, the symptoms observed, and the functional impairment reported. Your judgment is required both in averaging this data as well as weighing the reliability or \naccuracy of the data obtained and should be based on information obtained during the interview.]| <*Answer_7311*>| | 14. GLOBAL IMPROVEMENT:| Rate total overall improvement \npresent SINCE THE INITIAL RATING whether or not, in your judgment, it is due to treatment effects. | <*Answer_7312*>| | Items 13 and 14 are adapted from the Clinical Global Impression \nScale (Guy W: ECDEU Assessment Manual for Psychopharmacology: Publication 76-338. Washington, D.C., U.S. Department of Health, Education, and Welfare (1976)).| | Additional information regarding the \ndevelopment, use, and psychometric properties of the original YBOCS can be found in Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale (Y-BOCS): Part I. \nDevelopment, use, and reliability. Arch Gen Psychiatry (46:1006-1011, 1989). And Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scale (Y-BOCS): Part II. Validity. \nArch Gen Psychiatry (46:1012-1016, 1989). | | (c) Goodman, Rasmussen, Price, and Storch, 2006| | Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\ntime occupied by them in terms of total hours. In such cases, posing item #2 first may help identify most appropriate response to item #1. Be sure to exclude ruminations and preoccupations that, \nunlike obsessions, are ego-syntonic and rational - albeit excessive.)]| | <*Answer_7065*>| | 2. OBSESSION-FREE INTERVAL:| "On average, what is the longest continuous period \n(or block) of time in which you are free of obsessive thoughts?" [Only consider time while awake. You can also ask:] "How frequently do the obsessive thoughts occur?"| | <*Answer_7066*>| \n | 3. CONTROL OVER OBSESSIONS:| "How much control do you have over your obsessive thoughts? How successful are you in stopping or ignoring them? Can you dismiss them?"| | \n<*Answer_7067*>| | 4. DISTRESS OF OBSESSIONS:| "How much distress do your obsessive thoughts cause you?" [In most cases, distress is equated with anxiety; however, patients may report \n
\n\n"], ["138", "YBOCSII SYMPTOM LIST\n", "\n.| .| YBOCSII Symptom Checklist| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nattention, customer gets injured because you gave him wrong materials or information. | <*Answer_7084*>| 10. Fear might harm self or others on impulse. Examples: physically harming loved ones, \nstabbing or poisoning dinner guests, driving car into oncoming traffic, pushing stranger in front of a train. Distinguish from homicidal/suicidal intent. | <*Answer_7085*>| 11. Fear of being \nresponsible for terrible events. Examples: fire, burglary, flooding house, company going bankrupt, pipes freezing.| <*Answer_7086*>| 12. Fear of blurting out obscenities or insults. Examples: \nshouting blasphemies in church, yelling fire in the movie theatre, writing obscenities in a business letter.| <*Answer_7087*>| 13. Fear of doing something else embarrassing or inappropriate. \nExamples: sexual contact, spitting, taking off clothes in public, walking out with unpaid merchandise. Distinguish from social phobia.| <*Answer_7088*>| 14. Violent, horrific or repulsive \nimages. Examples: intrusive and disturbing| images of car crashes or disfigured people. Distinguish from PTSD.| <*Answer_7089*>| 15. Excessive concern with right/wrong or scrupulosity. \nExamples: worries about always doing "the right thing", unfounded worries about lying or cheating, didn't say prayers perfectly.| <*Answer_7090*>| 16. Concern with sacrilege or blasphemy. \nExamples: intrusive unacceptable| thoughts or images about God or religion. Concerns about adherence to religious| principles exceed those of religious peer group.| <*Answer_7091*>| 17. \nExcessive fears of Satan or demonic possession. Examples: fears triggered by "Red Devil" paint, sports teams with word devil in them, "666", pentangles.| <*Answer_7092*>| 18. Forbidden or \nimproper sexual thoughts or images. Examples: unwanted sexual thoughts about family members; images of unacceptable acts. Distinguish from paraphilias by asking about fantasy life.| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Questions and Answers| | 1. Excessive concern with germs. Examples: AIDS or hepatitis.| <*Answer_7076*>| 2. \n<*Answer_7093*>| 19. Experiences unwanted sexual impulses. Examples: concerned that might "snap" and commit sexual violation. Feels as if hand is moving toward someone's private parts in the absence \nof arousal. Distinguish from paraphilias. | <*Answer_7094*>| 20. Excessive concerns about sexual orientation or gender identity. Examples: person repeatedly wonders if s/he is gay \neven though there is every reason to believes s/he is heterosexual. Distinguish from realistic issues around sexual or gender identity. | <*Answer_7095*>| 21. Need for symmetry or exactness. \nExamples: certain things can't be touched or moved, clothes organized in closet alphabetically, bothered if pictures are not straight or canned goods not lined up.| <*Answer_7096*>| 22. \nPerfection in appearance or grooming. Examples: excessive concern about appearance of clothing, such as wrinkles, lint, loose threads; bothered if hair not parted exactly straight. Distinguish from \nOCPD. | <*Answer_7097*>| 23. Fear of saying the wrong thing. Ex: patient may appear to have thought blocking because she is reviewing every possible interpretation of what she is about to say.| \n <*Answer_7098*>| 24. Excessively bothered by things not sounding 'just right.' Examples: readjusting stereo system until it sounds 'just right'; asks family members to say things in just the \nright way, excessively bothered by visual, auditory or somatic sensations of not being 'just right'. | <*Answer_7099*>| 25. Need to know or remember. Examples: needing to remember insignificant \nthings like license plate numbers, bumper stickers, advertising slogans, names of actors.| <*Answer_7100*>| 26. Need to hoard or save things. Examples: afraid that something valuable might be \ndiscarded with recycled newspapers even though all valuables are locked up in the safe. Distinguish from hobbies and concern with objects of monetary or sentimental value. | <*Answer_7101*>| \nExcessive concern with contaminants or chemicals. Examples: household cleansers, asbestos, radiation, pesticides and toxic waste.| <*Answer_7077*>| 3. Concern will harm others by spreading \n27. Fear of losing objects, information, or a person. Examples: otherwise rational man feared "losing" his 5-year old daughter when mailing envelopes; patient concerned that her "essence" would be \nleft behind when getting up from a chair. | <*Answer_7102*>| 28. Magical or superstitious fears. Examples: colors with special significance(black connected with death, red associated with blood \nand injury), black cats, stepping on side walk cracks, (un)lucky numbers, getting pregnant from using a swimming pool. | <*Answer_7103*>| 29. Intrusive meaningless sounds, words, or music. \nExamples: songs or music with no special significance play over and over in one's mind like a broken record.| <*Answer_7104*>| 30. Excessive or ritualized hygiene. Examples: washes hands like \nsurgeon scrubbing for the operating room, uses harsh detergents or very hot water; takes long ritualized showers; excessive tooth brushing or toilet routine. | <*Answer_7105*>| 31. Cleaning of \nhousehold items, inanimate objects or pets. Examples: floors kept so clean you can eat off them; prolonged vacuuming; daily thorough washing of car tires.| <*Answer_7106*>| 32. Checking locks, \nstove, appliances, emergency brake, faucets, etc. Examples: Checking that the doors are locked, stove is turned off, appliances unplugged.| <*Answer_7107*>| 33. Checking that nothing terrible \ndid/will happen. Examples: makes sure that did not run over a pedestrian or did not leave cabinet open to poisonous substances, etc.| <*Answer_7108*>| 34. Checking that did not make mistake. \nExamples: homework, counting money, writing.| <*Answer_7109*>| 35. Checking tied to somatic obsessions. Examples: repeatedly probing groin to see if hernia is present; scrutinizing skin for \nsigns of cancer; excessive exploration of lymph nodes. Distinguish from hypochondriasis. | <*Answer_7110*>| 36. Need to repeat routine activities or boundary crossings. Examples: going through \ngerms or contaminants. Examples: transfer germs from one object to another.| <*Answer_7078*>| 4. Bothered by bodily waste or fluids. Examples: urine, feces, saliva or blood.| \ndoorway, crossing state lines; may get stuck trying to enter a building, doing/undoing rituals, taking clothes on/off, may have to repeat a certain number of times. | <*Answer_7111*>| 37. \nEvening up behaviors. Examples: movement on right side up body has to be balanced with same movement on left side; adjusts height of stockings, tension of shoelaces, plucks or cuts hair to achieve \nsymmetry. Distinguish latter from richotillomania, in which hair is not pulled for a specific purpose. | <*Answer_7112*>| 38. Re-reading or re-writing. Examples: doubt information that just \nread, written letters must look perfect. Distinguish from dyslexia.| <*Answer_7113*>| 39. Counting compulsions. Examples: counting things like ceiling or floor tiles,| books in a bookcase, \nwords in a sentence.| <*Answer_7114*>| 40. Ritualized activity of daily living routines. Example: may have to put clothes on in a certain order, can only go to bed after following an elaborate \nseries of steps, brush teeth in a ritualistic manner. | <*Answer_7115*>| 41. Excessive religious rituals. Example: Repeating prayers or passages from the Bible an inordinate number of times.| \n <*Answer_7116*>| 42. Ordering or arranging compulsions. Example: straightening piles of stationary on a desktop or adjusting books in a bookcase.| <*Answer_7117*>| 43. Repeating what \nsomeone else has said. Example: word, phrase, or sound. Distinguish from echolalia of Tourette's Syndrome.| <*Answer_7118*>| 44. Asking for reassurance. Example: repeatedly asking spouse that \nthey performed a routine correctly.| <*Answer_7119*>| 45. Ritualized eating behaviors. Ex: arrange or eat food in particular way or a specific order to avert a feared consequence other than \ngaining weight, as in anorexia nervosa.| <*Answer_7120*>| 46. Saves or collects useless items. Examples: piles up old newspapers, collects useless objects; house an become obstacle course with \n<*Answer_7079*>| 5. Bothered by sticky substances or residues. Examples: adhesives, chalk dust, or grease.| <*Answer_7080*>| 6. Excessive concern with becoming pregnant or of making someone \npiles of trash. Distinguish from hobbies and concern with objects of monetary or sentimental value. | <*Answer_7121*>| 47. Picks up objects that most people would pass by. Examples: shards of \nbroken glass, nails, pieces of paper with writing on them, staples.| <*Answer_7122*>| 48. Examines things that leave one's possession. Examples: sifts through garbage, ritual for washing off \ndinner plates to separate waste from accidentally lost items; won't throw out used disposable vacuum bags or the cat litter. | <*Answer_7123*>| 49. Buys many unneeded items. Examples: buys 20 \numbrellas, 100 boxes of moth balls, etc. May not be symptom of OCD unless behavior is excessive (e.g., wastes a lot of money, or accumulates closets full of unnecessary items.). | \n<*Answer_7124*>| 50. Need to tell, ask or confess things. Examples: confessing to sins or wrongs that didn't commit; feels must describe every detail so that nothing is left out; repeats the same \nquestion in different ways to make sure it was understood. | <*Answer_7125*>| 51. Need to do something until it feels "just right." Examples: adjusts car seat, straightens pictures, arranges \npapers on desk, doesn't let go of handshake, until feels an internal signal that its OK. Has no specific feared consequences in mind. | <*Answer_7126*>| 52. Need to touch, tap, or rub. \nExamples: urge to touch or run finger along surfaces or edges, lightly touches other people; taps a certain number of times; rubs against soft materials. May be difficult to distinguish from complex \nmotor tics of Tourette's. | <*Answer_7127*>| 53. Staring or blinking rituals. May be difficult to distinguish from motor tics of Tourettes Syndrome. If patient says has to blink a certain \nnumber or times or stare to neutralize an obsession, endorse as compulsions here. | <*Answer_7128*>| 54. Superstitious behaviors. Examples: steps over sidewalk cracks, spits after having an \npregnant. Example: Woman afraid of conception if she swims in public pool.| <*Answer_7081*>| 7. Concerned with having an illness/disease. It is not always clear where to draw the line between \nunwanted thought; makes sure sentences never contain 13 words; makes sign of the cross before dialing area code for New Jersey. | <*Answer_7129*>| 55. Mental rituals (other than checking or \ncounting). Examples: silently reciting prayers or nonsense words to neutralize unwanted thoughts.| <*Answer_7130*>| 56. Pervasive slowness. Extensive difficulty in starting, executing, and \nfinishing a wide range of routines tasks. In extreme cases, may be unable to complete tasks without assistance and may become"paralyzed". Distinguish from psychomotor retardation secondary to \ndepression or a primary movement disorder. | <*Answer_7131*>| 57. Ritualized avoidance. Examples: plans course on roadmap to stay at least 1 mile from chemical factories.| <*Answer_7132*>| \n 58. Active measures to avoid contact with contaminants or other feared objects. Ex: wears rubber gloves, doesn't shake hands, has one clean and one dirty hand, won't go near anyone who seems to have \na cut, won't sit down in a chair that has a red spot. | <*Answer_7133*>| 59. Avoids doing things, going places or being with someone because of obsessions.| <*Answer_7134*>| 60. Avoid \ncontact with contaminated objects or people.| <*Answer_7135*>| 61. Avoid handling sharp or dangerous objects, or operating vehicles or machinery, out of concern might harm others.| \n<*Answer_7136*>| 62. Avoid contact with people, children or animals because of unwanted impulses.| <*Answer_7137*>| 63. Avoids talking to or writing to others for fear will say or write the \nwrong thing.| <*Answer_7138*>| 64. Avoids watching TV, listening to radio or reading newspaper to shield from disturbing information.| <*Answer_7139*>| 65. Avoids going shopping out of \nconcern will buy extra items that aren't needed.| <*Answer_7140*>| 66. Avoids doing things, going places, or being with someone that would trigger time consuming or onerous rituals (e.g., \nsomatic obsessions and somatic preoccupations of hypochondriasis. Factors that point to OCD are the presence of compulsions not limited to seeking reassurance. | <*Answer_7082*>| 8. Fear of \nwashing, dressing, etc.).| <*Answer_7141*>| 67. Avoids reading or writing because it may bring on rituals (e.g., re-reading, re-writing).| <*Answer_7142*>| Obsession 1:| \n<*Answer_7143*>| Obsession 2:| <*Answer_7144*>| Obsession 3:| <*Answer_7145*>| Compulsion 1:| <*Answer_7146*>| Compulsion 2:| <*Answer_7147*>| Compulsion 3:| \n<*Answer_7148*>| Avoidance 1:| <*Answer_7149*>| Avoidance 2:| <*Answer_7150*>| Avoidance 3:| <*Answer_7151*>| | | Information contained in this note is based on a self-report \nassessment 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.| \n$~\neating certain foods. Examples: excessive concern about risks of certain foods or food preparations, afraid will choke, food will change body chemistry. Distinguish from anorexia nervosa, in which \nconcern is gaining weight. | <*Answer_7083*>| 9. Fear might harm self or others because not careful enough. Examples: parked car rolling down hill, hit a pedestrian because not paying \n
\n\n"], ["139", "FAD\n", "\n.| .| Family Assessment Device| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<*Answer_6755*>| 19. Some of us just don't respond emotionally.| <*Answer_6756*>| 20. We know what to do in an emergency.| <*Answer_6757*>| 21. We avoid discussing our fears and concerns.| \n <*Answer_6758*>| 22. It is difficult to talk to each other about tender feelings.| <*Answer_6759*>| 23. We have trouble meeting our bills.| <*Answer_6760*>| 24. After our family tries to \nsolve a problem, we usually discuss whether it worked or not.| <*Answer_6761*>| 25. We are too self-centered.| <*Answer_6762*>| 26. We can express feelings to each other.| \n<*Answer_6763*>| 27. We have no clear expectations about toilet habits.| <*Answer_6764*>| 28. We do not show our love for each other.| <*Answer_6765*>| 29. We talk to people directly rather \nthan through go-betweens.| <*Answer_6766*>| 30. Each of us has particular duties and responsibilities.| <*Answer_6767*>| 31. There are lots of bad feelings in the family.| \n<*Answer_6768*>| 32. We have rules about hitting people.| <*Answer_6769*>| 33. We get involved with each other only when something interest us.| <*Answer_6770*>| 34. There's little time to \nexplore personal interests.| <*Answer_6771*>| 35. We often don't say what we mean.| <*Answer_6772*>| 36. We feel accepted for what we are.| <*Answer_6773*>| 37. We show interest in each \nother when we can get something out of it personally.| <*Answer_6774*>| 38. We resolve most emotional upsets that come up.| <*Answer_6775*>| 39. Tenderness takes second place to other things \nin our family.| <*Answer_6776*>| 40. We discuss who is to do household jobs.| <*Answer_6777*>| 41. Making decisions is a problem for our family.| <*Answer_6778*>| 42. Our family shows \ninterest in each other only when they can get something out of it.| <*Answer_6779*>| 43. We are frank with each other.| <*Answer_6780*>| 44. We don't hold to any rules or standards.| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | Questions and Answers| | 1. Planning family activities is difficult because we misunderstand each \n<*Answer_6781*>| 45. If people are asked to do something, they need reminding.| <*Answer_6782*>| 46. We are able to make decisions about how to solve problems.| <*Answer_6783*>| 47. If the \nrules are broken, we don't know what to expect.| <*Answer_6784*>| 48. Anything goes in our family.| <*Answer_6785*>| 49. We express tenderness.| <*Answer_6786*>| 50. We confront problems \ninvolving feelings.| <*Answer_6787*>| 51. We don't get along well together.| <*Answer_6788*>| 52. We don't talk to each other when we are angry.| <*Answer_6789*>| 53. We are generally \ndissatisfied with the family duties assigned to us.| <*Answer_6790*>| 54. Even though we mean well, we intrude too much into each others lives.| <*Answer_6791*>| 55. There are rules about \ndangerous situations.| <*Answer_6792*>| 56. We confide in each other.| <*Answer_6793*>| 57. We cry openly.| <*Answer_6794*>| 58. We don't have reasonable transport.| <*Answer_6795*>| \n59. When we don't like what someone has done, we tell them.| <*Answer_6796*>| 60. We try to think of different ways to solve problems.| <*Answer_6797*>| | | Information contained in this note \nis 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 \nactivities and procedures.| $~\nother.| <*Answer_6738*>| 2. We resolve most everyday problems around the house.| <*Answer_6739*>| 3. When someone is upset the others know why.| <*Answer_6740*>| 4. When you ask someone \nto do something, you have to check that they did it.| <*Answer_6741*>| 5. If someone is in trouble, the others become too involved.| <*Answer_6742*>| 6. In times of crisis we can turn to each \nother for support.| <*Answer_6743*>| 7. We don't know what to do when an emergency comes up.| <*Answer_6744*>| 8. We sometimes run out of things that we need.| <*Answer_6745*>| 9. We are \nreluctant to show our affection for each other.| <*Answer_6746*>| 10. We make sure members meet their family responsibilities.| <*Answer_6747*>| 11. We cannot talk to each other about the \nsadness we feel.| <*Answer_6748*>| 12. We usually act on our decisions regarding problems.| <*Answer_6749*>| 13. You only get the interest of others when something is important to them.| \n<*Answer_6750*>| 14. You can't tell how a person is feeling from what they are saying.| <*Answer_6751*>| 15. Family tasks don't get spread around enough.| <*Answer_6752*>| 16. Individuals are \naccepted for what they are.| <*Answer_6753*>| 17. You can easily get away with breaking the rules.| <*Answer_6754*>| 18. People come right out and say things instead of hinting at them.| \n
\n\n"], ["14", "POQ\n", "\n.|.|Pain Outcomes Questionnaire||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \naffect your self-esteem or self-worth?| <*Answer_5148*>|12. How would you rate your physical activity?| <*Answer_5149*>|13. How would you rate your overall energy?| <*Answer_5150*>|14. How \nwould you rate your strength and endurance TODAY?| <*Answer_5151*>|15. How would you rate your feelings of depression TODAY?| <*Answer_5152*>|16. How would you rate your feelings of anxiety \nTODAY?| <*Answer_5153*>|17. How much do you worry about re-injuring yourself if you are more active?| <*Answer_5154*>|18. How safe do you think it is for you to exercise?| \n<*Answer_5155*>|19. Do you have problems concentrating on things TODAY?| <*Answer_5156*>|20. How often do you feel tense?| <*Answer_5157*>|||Information contained in this note is based on a \nself-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 \nprocedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| POQ Scale Raw Inpatient Outpatient| Score Percentile Percentile|<*Answer_999999999999*>| Higher percentile scores denote \nVeteran's self-reports of increased symptom| severity when compared to comparison groups of Veterans with pain treated | in inpatient or outpatient multidisciplinary pain settings. ||Questions and Answers||1. Today's date:| \n <*Answer_5138*>|2. On a scale of 0 to 10, with 0 being no pain at \nall and 10 being the worst possible pain, how would you rate your pain on the AVERAGE during the LAST WEEK?| <*Answer_5139*>|3. Does your pain interfere with your ability to walk?| \n<*Answer_5140*>|4. Does your pain interfere with your ability to carry/handle everyday objects such as a bag of groceries or books?| <*Answer_5141*>|5. Does your pain interfere with your ability \nto climb stairs?| <*Answer_5142*>|6. Does your pain require you to use a cane, walker, wheelchair or other devices?| <*Answer_5143*>|7. Does your pain interfere with your ability to bathe \nyourself?| <*Answer_5144*>|8. Does your pain interfere with your ability to dress yourself?| <*Answer_5145*>|9. Does your pain interfere with your ability to use the bathroom?| \n<*Answer_5146*>|10. Does your pain interfere with your ability to manage your personal grooming (for example, combing your hair, brushing your teeth, etc.)?| <*Answer_5147*>|11. Does your pain \n
\n\n"], ["140", "SIP-2L\n", "\n.| .| Short Inventory of Problems - 2L| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \npopularity, or reputation.| <*Answer_7164*>| 14. I have spent too much or lost a lot of money because of my drinking.| <*Answer_7165*>| 15. I have had an accident while drinking or \nintoxicated.| <*Answer_7166*>| | | | All material appearing in this instrument is in the public domain and may be reproduced or copied without permission from the Institute or the \nauthors. Citation of the source is appreciated. NIH Publication No. 95-3911 Printed 1995| | Information contained in this note is based on a self-report assessment and is not sufficient to use \nalone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | SIP-2L scale scores | | Physical: \n<-Physical->| Inter-Personal: <-Inter-Personal->| Intra-Personal: <-Intra-Personal->| Impulse Control: <-Impulse Control->| Social Responsibility: \n<-Social Responsibility->| | Total: <-Total-> | | Questions and Answers| | 1. I have been unhappy because of my drinking.| <*Answer_7152*>| 2. \nBecause of my drinking, I have not eaten properly.| <*Answer_7153*>| 3. I have failed to do what is expected of me because of my drinking.| <*Answer_7154*>| 4. I have felt guilty or \nashamed because of my drinking.| <*Answer_7155*>| 5. I have taken foolish risks when I have been drinking.| <*Answer_7156*>| 6. When drinking, I have done impulsive things that I \nregretted later.| <*Answer_7157*>| 7. My physical health has been harmed by my drinking.| <*Answer_7158*>| 8. I have had money problems because of my drinking.| <*Answer_7159*>| \n 9. My physical appearance has been harmed by my drinking.| <*Answer_7160*>| 10. My family has been hurt by my drinking.| <*Answer_7161*>| 11. A friendship or close relationship has \nbeen damaged by my drinking.| <*Answer_7162*>| 12. My drinking has gotten in the way of my growth as a person.| <*Answer_7163*>| 13. My drinking has damaged my social life, \n
\n\n"], ["141", "QOLIE-31\n", "\n.| .| Quality of Life in Epilespy - QOLIE-31| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nDriving?| <*Answer_7203*>| 21. How fearful are you of having a seizure during the next month?| <*Answer_7204*>| 22. Do you worry about hurting yourself during a seizure?| <*Answer_7205*>| \n23. How worried are you about embarrassment or other social problems resulting from having a seizure during the next month?| <*Answer_7206*>| 24. How worried are you that medications you are \ntaking will be bad for you if taken for a long time?| <*Answer_7207*>| 25. Seizures| <*Answer_7208*>| 26. Memory difficulties| <*Answer_7209*>| 27. Work limitations| <*Answer_7210*>| \n28. Social limitations| <*Answer_7211*>| 29. Physical effects of antiepileptic medication| <*Answer_7212*>| 30. Mental effects of antiepileptic medication| <*Answer_7213*>| 31. How good \nor bad do you think your health is?| <*Answer_7214*>| 32. Comments (if any)| <*Answer_7215*>| | Copyright 1993, RAND. All Rights reserved. The QOLIE-31 was developed in cooperation with \nProfessional Postgraduate Services, a division of Phys World Comm Group, and the QOLIE Development Group.| | | Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Overall, how would you rate your quality of life?| <*Answer_7184*>| 2. \nDid you feel full of pep?| <*Answer_7185*>| 3. Have you been a very nervous person?| <*Answer_7186*>| 4. Have you felt so down in the dumps that nothing could cheer you up?| \n<*Answer_7187*>| 5. Have you felt calm and peaceful?| <*Answer_7188*>| 6. Did you have a lot of energy?| <*Answer_7189*>| 7. Have you felt downhearted and blue?| <*Answer_7190*>| 8. Did \nyou feel worn out?| <*Answer_7191*>| 9. Have you been a happy person?| <*Answer_7192*>| 10. Did you feel tired?| <*Answer_7193*>| 11. Have you worried about having another seizure?| \n<*Answer_7194*>| 12. Did you have difficulty reasoning and solving problems (such as making plans, making decisions, learning new things)?| <*Answer_7195*>| 13. Has your health limited your \nsocial activities (such as visiting with friends or close relatives)?| <*Answer_7196*>| 14. How has the QUALITY OF YOUR LIFE been during the past 4 weeks (that is, how have things been going for \nyou)?| <*Answer_7197*>| 15. In the past 4 weeks, have you had any trouble with your memory?| <*Answer_7198*>| 16. Trouble remembering things people tell you?| <*Answer_7199*>| 17. Trouble \nconcentrating or reading?| <*Answer_7200*>| 18. Trouble concentrating or doing one thing at a time?| <*Answer_7201*>| 19. Leisure time (such as hobbies, going out)?| <*Answer_7202*>| 20. \n
\n\n"], ["142", "QOLIE-31\n", "\n.| .| Quality of Life in Epilespy - QOLIE-31| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nDriving?| <*Answer_7203*>| 21. How fearful are you of having a seizure during the next month?| <*Answer_7204*>| 22. Do you worry about hurting yourself during a seizure?| <*Answer_7205*>| \n23. How worried are you about embarrassment or other social problems resulting from having a seizure during the next month?| <*Answer_7206*>| 24. How worried are you that medications you are \ntaking will be bad for you if taken for a long time?| <*Answer_7207*>| 25. Seizures| <*Answer_7208*>| 26. Memory difficulties| <*Answer_7209*>| 27. Work limitations| <*Answer_7210*>| \n28. Social limitations| <*Answer_7211*>| 29. Physical effects of antiepileptic medication| <*Answer_7212*>| 30. Mental effects of antiepileptic medication| <*Answer_7213*>| 31. How good \nor bad do you think your health is?| <*Answer_7214*>| 32. Comments (if any)| <*Answer_7215*>| | | Copyright 1993. RAND. All rights reserved. The QOLIE-31 was developed in cooperation with \nProfessional Postgraduate Services, a division of Physicians World Communications Group, and the QOLIE Development Group.| | Information contained in this note is based on a self-report assessment \nand 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.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | | Questions and Answers| | 1. Overall, how would you rate your quality of life?| <*Answer_7184*>| 2. \nDid you feel full of pep?| <*Answer_7185*>| 3. Have you been a very nervous person?| <*Answer_7186*>| 4. Have you felt so down in the dumps that nothing could cheer you up?| \n<*Answer_7187*>| 5. Have you felt calm and peaceful?| <*Answer_7188*>| 6. Did you have a lot of energy?| <*Answer_7189*>| 7. Have you felt downhearted and blue?| <*Answer_7190*>| 8. Did \nyou feel worn out?| <*Answer_7191*>| 9. Have you been a happy person?| <*Answer_7192*>| 10. Did you feel tired?| <*Answer_7193*>| 11. Have you worried about another seizure?| \n<*Answer_7194*>| 12. Did you have difficulty reasoning and solving problems (such as making plans, making decisions, learning new things)?| <*Answer_7195*>| 13. Has your health limited your \nsocial activities (such as visiting with friends or close relatives)?| <*Answer_7196*>| 14. How has your QUALITY OF LIFE been during the past 4 weeks (that is, how have things been going for \nyou)?| <*Answer_7197*>| 15. In the past 4 weeks, have you had any trouble with your memory?| <*Answer_7198*>| 16. Trouble remembering things people tell you?| <*Answer_7199*>| 17. Trouble \nconcentrating or reading?| <*Answer_7200*>| 18. Trouble concentrating or doing one thing at a time?| <*Answer_7201*>| 19. Leisure time (such as hobbies, going out)?| <*Answer_7202*>| 20. \n
\n\n"], ["143", "CCSA-DSM5\n", "\n.| .| Cross-Cutting Symptom Assessment for DSM-5| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \nor hopeless?| <*Answer_7217*>| 3. Feeling more irritated, grouchy, or angry than usual?| <*Answer_7218*>| 4. Sleeping less than usual, but still have a lot of energy?| <*Answer_7219*>| 5. \nStarting lots more projects than usual or doing more risky things than usual?| <*Answer_7220*>| 6. Feeling nervous, anxious, frightened, worried, or on edge?| <*Answer_7221*>| 7. Feeling \npanic or being frightened?| <*Answer_7222*>| 8. Avoiding situations that make you anxious?| <*Answer_7223*>| 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?| \n<*Answer_7224*>| 10. Feeling that your illnesses are not being taken seriously enough?| <*Answer_7225*>| 11. Thoughts of actually hurting yourself?| <*Answer_7226*>| 12. Hearing things other \npeople couldnt hear, such as voices even when no one was around?| <*Answer_7227*>| 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?| \n<*Answer_7228*>| 14. Problems with sleep that affected your sleep quality over all?| <*Answer_7229*>| 15. Problems with memory (e.g., learning new information) or with location (e.g., finding way \nhome)?| <*Answer_7230*>| 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?| <*Answer_7231*>| 17. Feeling driven to perform certain behaviors or mental acts over and \nover again?| <*Answer_7232*>| 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?| <*Answer_7233*>| 19. Not knowing who you really are or \nwhat you want out of life?| <*Answer_7234*>| 20. Not feeling close to other people or enjoying your relationships with them?| <*Answer_7235*>| 21. Drinking at least 4 drinks of any kind of \nalcohol in a single day?| <*Answer_7236*>| 22. Smoking any cigarettes, a cigar, or pipe or using snuff or chewing tobacco?| <*Answer_7237*>| 23. Using any of the following medicines ON YOUR \nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |Items/domains with a rating of MILD OR GREATER (or SLIGHT OR GREATER for items 21-23/Substance Use domain, 11/suicidal ideation \nOWN, that is, without a doctors prescription, in greater amounts or longer than prescribed: painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like \nsleeping pills or Valium), or drugs marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or meth (like speed)? | \n <*Answer_7238*>| | | Copyright (c) 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their \npatients.| | 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 \nand used in conjunction with other diagnostic activities and procedures.| $~\nand 12-13/psychosis )indicate the need for additional assessment.| | | Domain Results | | Domain Screening Results| |\n I. Depression...................................<*Answer_7771*>| II. Anger........................................<*Answer_7772*>| III. Mania........................................<*Answer_7773*>|\n IV. Anxiety......................................<*Answer_7774*>| V. Somatic Symptoms.............................<*Answer_7775*>| VI. Suicidal Ideation............................<*Answer_7776*>|\n VII. Psychosis....................................<*Answer_7777*>| VIII. Sleep Problems...............................<*Answer_7778*>| IX. Memory.......................................<*Answer_7779*>|\n X. Repetitive Thoughts and Behaviors............<*Answer_7780*>| XI. Dissociation.................................<*Answer_7781*>|\n XII. Personality Functioning......................<*Answer_7782*>| XIII. Substance Use................................<*Answer_7783*>|\n| Questions and Answers| | 1. Little interest or pleasure in doing things?| <*Answer_7216*>| 2. Feeling down, depressed, \n
\n\n"], ["144", "SMEQ\n", "\n.| .| Smith Morning-Evening Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nhears about "morning" and "evening" type people. Which ONE of these types do you consider yourself to be?| <*Answer_7247*>| 10. When would you prefer to rise (provided you have a full day's work \n- 8 hours) if you were totally free to arrange your time?| <*Answer_7248*>| 11. If you always had to rise at 6:00 am, what do you think it would be like?| <*Answer_7249*>| 12. How long a time \ndoes it usually take before you "recover your senses" in the morning after rising from a night's sleep?| <*Answer_7250*>| 13. Please indicate to what extent you are a morning or an evening active \nindividual?| <*Answer_7251*>| | | 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 \nverified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | SMEQ Score: <-SMEQ->| | | Scoring: Evening Type: 22 and less| Intermediate Type: 23 - 43| \nMorning Type: 44 and above| | Questions and Answers| | 1. Considering only your own "feeling best" rhythm, at what time would you get up if you were entirely free to plan your day?| \n<*Answer_7239*>| 2. Considering only your own "feeling best" rhythm, at what time would you go to bed if you were entirely free to plan your evening?| <*Answer_7240*>| 3. Assuming normal \ncircumstances, how easy do you find getting up in the morning?| <*Answer_7241*>| 4. How alert do you feel after the first half hour after having awakened in the morning?| <*Answer_7242*>| 5. \nDuring the first half hour after having awakened in the morning, how tired do you feel?| <*Answer_7243*>| 6. You have decided to engage in some physical exercise. A friend suggests that you do \nthis one hour twice a week and the best time for him is 7:00-8:00 am. Bearing in mind nothing else but your "feeling best" rhythm, how do you think you would perform? | <*Answer_7244*>| 7. At \nwhat time in the evening do you feel tired and as a result, in need of sleep?| <*Answer_7245*>| 8. You wish to be at your peak performance for a test, which you know is going to be mentally \nexhausting and lasting for two hours. You are entirely free to plan your day, and considering only your own" feeling best" rhythm, which ONE of the four testing ti | <*Answer_7246*>| 9. One \n
\n\n"], ["145", "AAQ-SA\n", "\n.| .| The Acceptance and Action Questionnaire -Substance Abuse| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nbe weak-willed.| <*Answer_7264*>| 14. People would be scared of me if they knew about my substance abuse history.| <*Answer_7265*>| 15. If someone were to find out about my history of \nsubstance use, they would doubt my character.| <*Answer_7267*>| 16. People will think I have little talent or skill if they know about my substance history.| <*Answer_7266*>| 17. People think \nthe bad things that have happened to me are my fault.| <*Answer_7268*>| | Section 3:| | 18. I would choose to avoid someone who seemed interested in my friendship if I knew they had never used \nsubstances.| <*Answer_7269*>| 19. I do things that are good for me, even if I feel like I don't deserve it.| <*Answer_7270*>| 20. If something is important to me, I keep doing it, even if I \nfeel incompetent.| <*Answer_7271*>| 21. When I feel incompetent at something I want to do, I stop trying.| <*Answer_7272*>| 22. I'm willing to be in situations where I might feel different \nfrom others.| <*Answer_7273*>| 23. I am getting on with the business of living, no matter how guilty I feel.| <*Answer_7274*>| 24. I am open about my substance use history with most people.| \n <*Answer_7275*>| 25. I put a lot of effort into hiding my substance use history.| <*Answer_7276*>| 26. I avoid doing things where I would be blamed if it didn't work out.| <*Answer_7277*>| \n27. I wouldn't try to fill roles that required a person of character.| <*Answer_7278*>| 28. Shame gets in the way of how I want to live my life.| <*Answer_7279*>| 29. I pursue important goals \nin life, even when I fear I might not follow through.| <*Answer_7280*>| 30. I can set a direction for my life even if I feel hopeless.| <*Answer_7281*>| 31. Even if I knew the employer didn't \nlike to hire people in recovery, I would still apply for a job if it interested me.| <*Answer_7282*>| 32. I would lie to people in my life about my substance use if I were sure they would never \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | AAQ-SA| Self devaluation: <-Self devaluation->| Fear of enacted stigma: <-Fear of enacted \nfind out.| <*Answer_7283*>| 33. I avoid situations where another person might have to depend on me.| <*Answer_7284*>| 34. I avoid situations that make me feel different.| <*Answer_7285*>| \n35. I can't stand feeling like the bad things that happen to me are my fault.| <*Answer_7286*>| 36. I would willingly sacrifice important things in my life to feel like I fit in.| \n<*Answer_7287*>| 37. Blaming myself for my substance abuse history gets in the way of my success.| <*Answer_7288*>| 38. I can set a course in my life and stick to it, even when I feel like I'm a \nbad person.| <*Answer_7289*>| 39. If I didn't have a job, I would still look for one, even if it felt hopeless.| <*Answer_7290*>| 40. I would willingly sacrifice important life goals if that \nmeant I could feel better about myself.| <*Answer_7291*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nstigma->| Stigma avoidance: <-Stigma avoidance->| Values disengagement: <-Values disengagement->| | Questions and Answers| | Section 1:| | 1. I have the thought that a major reason for my \nproblems with substances is my own poor character.| <*Answer_7252*>| 2. I have the thought that I should be ashamed of myself.| <*Answer_7253*>| 3. I have the thought that I deserve the bad \nthings that have happened to me.| <*Answer_7254*>| 4. I have the thought that I can't be trusted.| <*Answer_7255*>| 5. I feel inferior to people who have never had a problem with substances.| \n <*Answer_7256*>| 6. I feel out of place in the world because of my problems with substances.| <*Answer_7257*>| 7. I have the thought that I've permanently screwed up my life by using drugs.| \n <*Answer_7258*>| 8. I feel ashamed of myself.| <*Answer_7259*>| | Section 2:| | 9. People think I'm worthless if they know about my substance use history.| <*Answer_7260*>| 10. People \naround me will always suspect I have returned to using substances.| <*Answer_7261*>| 11. People without a substance use history could never really understand me.| <*Answer_7262*>| 12. A job \ninterviewer wouldn't hire me if I mentioned my substance history in a job interview.| <*Answer_7263*>| 13. If someone were to find out about my history of substance use, they would expect me to \n
\n\n"], ["146", "CIWA-AR-\n", "\n.| .| Clinical Institute Withdrawal Assessment - Alcohol Revised| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nto you? Are you seeing things you know are not there?" Observation: | <*Answer_7321*>| 12. HEADACHE, FULLNESS IN HEAD - Ask, "Does your head feel different? Does it feel like there is a band \naround your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity:| <*Answer_7323*>| 13. ORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who \nam I?"| <*Answer_7325*>| | | 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 \nverified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | CIWA-AR| Total Score: <-Total Score->| | Scores of less than 8 indicate mild withdrawal, 8-15\n indicate moderate| withdrawal (marked autonomic arousal) and >15 indicate severe withdrawal| and are also predictive of the development of seizures and delirium.| | Questions and Answers| | 1. \nTime (use 24 hour clock, midnight is 00:00):| <*Answer_7313*>| 2. Pulse or heart rate (taken for one minute):| <*Answer_7314*>| 3. Blood pressure:| <*Answer_7315*>| 4. NAUSEA AND VOMITING \n- Ask, "Do you feel sick to your stomach? Have you vomited?" Observation:| <*Answer_7316*>| 5. TREMOR - Arms extended and fingers spread apart. Observation:| <*Answer_7318*>| 6. PAROXYSMAL \nSWEATS - Observation:| <*Answer_7320*>| 7. ANXIETY - Ask, "Do you feel nervous?" Observation:| <*Answer_7322*>| 8. AGITATION - Observation:| <*Answer_7324*>| 9. TACTILE DISTURBANCES - \nAsk, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation:| <*Answer_7317*>| 10. AUDITORY DISTURBANCES - \nAsk, "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" \nObservation: | <*Answer_7319*>| 11. VISUAL DISTURBANCES - Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing \n
\n\n"], ["147", "CSI-4\n", "\n\n.| .| Couple Satisfaction Index-4| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | CSI-4 Score: <-CSI-4->| | | Questions and Answers| | 1. Please indicate the degree of happiness, all things considered,\n of your relationship.| <*Answer_6484*>| 2. I have a warm and comfortable relationship with my partner.| <*Answer_6488*>| 3. How rewarding is your relationship with your partner?|\n <*Answer_6492*>| 4. In general, how satisfied are you with your relationship?| <*Answer_6559*>|\n| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results\n should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["148", "CSI-4 PARTNER VERSION\n", "\n\n.| .| Couple Satisfaction Index-4 Partner Version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | CSI-4 Partner Score: <-CSI-4PT->| | | 1. Partner's Name: <*Answer_7337*>| | | Questions and Answers| |\n 2. Please indicate the degree of happiness, all things considered of your relationship.| <*Answer_7336*>| 3. I have a warm and comfortable relationship with my partner.|\n <*Answer_6488*>| 4. How rewarding is your relationship with your partner?| <*Answer_6492*>| 5. In general, how satisfied are you with your relationship?| <*Answer_6559*>|\n| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results\n should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["149", "CSI PARTNER VERSION\n", "\n.| .| Couple Satisfaction Index Partner Version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nconjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | CSI Partner Score: <-CSI-PV->| | | 1. Partner's Name: <*Answer_7337*>| | | Questions and Answers| | 2. Please indicate the degree of happiness, all things considered, \nof your relationship.| <*Answer_7336*>| 3. In general, how often do you think that things between you and your partner are going well?| <*Answer_6485*>| 4. Our relationship is strong.| \n<*Answer_6486*>| 5. My relationship with my partner makes me happy.| <*Answer_6487*>| 6. I have a warm and comfortable relationship with my partner.| <*Answer_6488*>| 7. I really feel like \npart of a team with my partner.| <*Answer_6491*>| 8. How rewarding is your relationship with your partner?| <*Answer_6492*>| 9. How well does your partner meet your needs?| \n<*Answer_6494*>| 10. To what extent has your relationship met your original expectations?| <*Answer_6497*>| 11. In general, how satisfied are you with your relationship?| <*Answer_6559*>| 12. \nMy relationship is boring vs. interesting:| <*Answer_6732*>| 13. My relationship is bad vs. good:| <*Answer_6733*>| 14. My relationship is empty vs. full:| <*Answer_6734*>| 15. My \nrelationship is fragile vs. sturdy:| <*Answer_6735*>| 16. My relationship is discouraging vs. hopeful:| <*Answer_6736*>| 17. My relationship is miserable vs. enjoyable:| <*Answer_7294*>| \n| | 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 \n
\n\n"], ["15", "WHYMPI\n", "\n.|.|West Haven-Yale Multidimensional Pain Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \npain problem interfere with your day to day activities?| <*Answer_5203*>|Are you retired from work for reasons other than your pain problem?| <*Answer_5204*>|A3. Since the time you developed a \npain problem, how much has your pain changed your ability to work?| <*Answer_5205*>|A4. How much has your pain changed the amount of satisfaction or enjoyment you get from participating in social \nand recreational activities?| <*Answer_5206*>|A5. How supportive or helpful is your spouse (significant other) to you in relation to your pain?| <*Answer_5207*>|A6. Rate your overall mood \nduring the PAST WEEK.| <*Answer_5208*>|A7. On the average, how severe has your pain been during the LAST WEEK?| <*Answer_5209*>|A8. How much has your pain changed your ability to participate in \nrecreational and other social activities?| <*Answer_5210*>|A9. How much has your pain changed the amount of satisfaction you get from family-related activities?| <*Answer_5211*>|A10. How \nworried is your spouse (significant other) about you in reaction to your pain problem?| <*Answer_5212*>|A11. During the PAST WEEK, how much control do you feel that you have had over your life?| \n <*Answer_5213*>|A12. How much SUFFERING do you experience because of your pain?| <*Answer_5214*>|A13. How much has your pain changed your marriage and other family relationships?| \n<*Answer_5215*>|Are you currently working?| <*Answer_5216*>|A14. How much has your pain changed the amount of satisfaction or enjoyment you get from work?| <*Answer_5217*>|A15. How attentive is \nyour spouse (significant other) to your pain problem?| <*Answer_5218*>|A16. During the PAST WEEK, how much do you feel that you've been able to deal with your problems?| <*Answer_5219*>|A17. \nHow much has your pain changed your ability to do household chores?| <*Answer_5220*>|A18. During the PAST WEEK, how irritable have you been?| <*Answer_5221*>|A19. How much has your pain changed \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |WHYMPI Scales||Part I| Interference <-Interference->| Support <-Support->| Pain Severity \nyour friendships with people other than your family?| <*Answer_5222*>|A20. During the PAST WEEK, how tense or anxious have you been?| <*Answer_5223*>|B1. Ignores me.| <*Answer_5225*>|B2. \nAsks me what he/she can do to help.| <*Answer_5226*>|B3. Reads to me.| <*Answer_5227*>|B4. Expresses irritation at me.| <*Answer_5228*>|B5. Takes over my jobs or duties.| \n<*Answer_5229*>|B6. Talks to me about something else to take my mind off the pain.| <*Answer_5230*>|B7. Expresses frustration with me.| <*Answer_5231*>|B8. Tries to get me to rest.| \n<*Answer_5232*>|B9. Tries to involve me in some activity.| <*Answer_5233*>|B10. Expresses anger with me.| <*Answer_5234*>|B11. Gets me some pain medication.| <*Answer_5235*>|B12. Encourages \nme to work on a hobby.| <*Answer_5236*>|B13. Gets me something to eat or drink.| <*Answer_5237*>|B14. Turns on the TV to take my mind off my pain.| <*Answer_5238*>|C1. Washes dishes.| \n<*Answer_5239*>|C2. Mow the lawn.| <*Answer_5240*>|C3. Go out to eat.| <*Answer_5241*>|C4. Play cards or other games.| <*Answer_5242*>|C5. Go grocery shopping.| <*Answer_5243*>|C6. Work \nin the garden.| <*Answer_5244*>|C7. Go to a movie.| <*Answer_5245*>|C8. Visit a friend.| <*Answer_5246*>|C9. Help with the house cleaning.| <*Answer_5247*>|C10. Work on a car.| \n<*Answer_5248*>|C11. Take a ride in a car.| <*Answer_5249*>|C12. Visit relatives.| <*Answer_5250*>|C13. Prepare a meal.| <*Answer_5251*>|C14. Wash the car.| <*Answer_5252*>|C15. Take a \ntrip.| <*Answer_5253*>|C16. Go to a park or beach.| <*Answer_5254*>|C17. Do a load of laundry.| <*Answer_5255*>|C18. Work on a needed house repair.| <*Answer_5256*>|||Information \ncontained 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 \n <-Pain Severity->| Life-Con\nwith other diagnostic activities and procedures.||Copyright (c) 1985, Robert D. Kerns, Dennis C. Turk and Thomas E. Rudy.| $~\ntrol <-Life-Control->| Affective Distress <-Affective Distress->||Part II| Negative Responses <-Negative Responses->| Solicitous Responses \n <-Solicitous Responses->| Distracting Responses <-Distracting Responses->|\n|Part III| Household Chores <-Household Chores->| Outdoor Work <-Outdoor Work->| Activities Away from Home <-Activities Away from Home->| Social Activities \n<-Social Activities->| General Activity <-General Activity->||Questions and Answers||1.\nPlease indicate who your significant other is:| <*Answer_5199*>|Significant\n other:| <*Answer_5200*>|2. Do you currently live with this person?| <*Answer_5201*>|A1. Rate the level of your pain at the present moment.| <*Answer_5202*>|A2. In general, how much does your \n
\n\n"], ["150", "PHQ-2+I9\n", "\n| | Patient Health Questionnaire-2 + Item9(PHQ-2+I9)|\n \n| PHQ-2+I9 Suicide Screening Score: <-Suicide Ideation->\n| <*Answer_7773*>| <*Answer_7774*>\n| | Questions and Answers|\n 1. Little interest or pleasure in doing things| <*Answer_7799*>|\n 2. Feeling down, depressed, or hopeless| <*Answer_7800*>|\n 3. Thoughts that you would be better off dead or of hurting yourself |\n in some way| <*Answer_7788*>|\n \n| |Information contained in this note is based on a self-report assessment \n| Date Given: <.Date_Given.>\n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with other \n|diagnostic activities.\n \n \n| |Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke\n|and colleagues, with an educational grant from Pfizer Inc. No permission\n|required to reproduce, translate, display or distribute.\n$~ \n| Clinician: <.Staff_Ordered_By.>\n| Location:<.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| |\n \n| PHQ-2+I9 Depression Screening Score: <-Depression->\n| <*Answer_7771*>| <*Answer_7772*>|\n
\n\n"], ["151", "PSS-3\n", "\n|.|.|Patient Safety Screener 3 (PSS-3) |\n depressed, or hopeless? | <*Answer_7789*>| 2. Over the past 2 weeks,\nhave you had thoughts of killing yourself? | <*Answer_7790*>| 3. In \nyour lifetime, have you ever attempted to kill yourself? |\n <*Answer_7791*>|\n 3.1. If "Yes": When was the last time you attempted to kill yourself?\n| <*Answer_7792*>| | \n \n \n| |Information contained in this note is based on a self-report\n|assessment and is not sufficient to use alone for diagnostic purposes.\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n|Assessment results should be verified for accuracy and used in\n|conjunction with other diagnostic activities.\n \n| |Copyright 2016. Emergency Medicine Network. Reproduced with Permission of author.\n \n$~\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| | | Depressed Mood Scale | \n <*Answer_7771*>|| \n Active Suicidal Ideation Scale| <*Answer_7772*>|| \n Recent Suicide Attempt Scale| <*Answer_7773*>||\n Questions and Answers:| 1. Over the past 2 weeks, have you felt down,\n
\n\n"], ["152", "PC-PTSD-5\n", "\n| | PTSD Screen - (PC-PTSD-5)\n| PC-PTSD-5 Screening Score: <-PTSD5->| \n|<*Answer_7771*>|<*Answer_7772*>| |\n \nQuestions and Answers|\n Sometimes things happen to people that are unusually or especially|\n frightening, horrible, or traumatic. For example:|\n A serious accident or fire|\n A physical or sexual assault or abuse|\n An earthquake or flood|\n A war|\n| Date Given: <.Date_Given.>\n Seeing someone be killed or seriously injured|\n Having a loved one die through homicide or suicide| |\n 1. Have you ever experienced this kind of event? | <*Answer_7793*>|\n 2. Had nightmares about the event(s) when you did not want to?| <*Answer_7794*>|\n 3. Tried hard not to think about the event(s) or went out of your way to|\n avoid situations that remind you of the event(s)?| <*Answer_7795*>|\n 4. Been constantly on guard, watchful, or easily startled?| <*Answer_7796*>|\n 5. Felt numb or detached from people, activities, or your surroundings?| <*Answer_7797*>|\n 6. Felt guilty or unable to stop blaming yourself or others for the|\n event(s) or any problems the event(s) may have caused?| <*Answer_7798*>|\n| Clinician: <.Staff_Ordered_By.>\n \n| |Information contained in this note is based on a self-report assessment and\n|is not sufficient to use alone for diagnostic purposes. Assessment results\n|should be verified for accuracy and used in conjunction with other diagnostic\n|activities and procedures.\n \n| |PC-PTSD-5, 2015, National Center for PTSD\n \n$~\n| Location: <.Location.>\n| | Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| | \n \n
\n\n"], ["153", "C-SSRS\n", "\n| | Columbia Suicide Severity Rating Scale (C-SSRS) | | \n|<*Answer_7774*>||\n Questions and Answers: ||\n 1. Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?| <*Answer_7801*>|\n 2. Over the past month, have you had any actual thoughts of killing yourself? | <*Answer_7802*>|\n 3. Over the past month, have you been thinking about how you might do this? | <*Answer_7803*>|\n 4. Over the past month, have you had these thoughts and had some intention of acting on them? | <*Answer_7804*>|\n 5. Over the past month, have you started to work out or worked out the details of how to kill yourself?| <*Answer_7805*>|\n 6. If yes, at any time in the past month did you intend to carry out this plan?| <*Answer_7806*>|\n 7. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills,\n obtained a gun, gave away valuables, went to the roof but didn't jump)?| <*Answer_7807*>|\nDate Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.> |\n 8. If yes, was this within the past 3 months?| <*Answer_7808*> ||\n \n| |Columbia-Suicide Severity Rating Scale (C-SSRS) 2016 The Columbia Lighthouse Project. Scale may be reproduced without permission.\n \n| |Information contained in this note is based on a self-report\n assessment and is not sufficient to use alone for diagnostic purposes.\n Assessment results should be verified for accuracy and used in\n conjunction with other diagnostic activities. $~\n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.> | |\n| Suicidal Ideation in Past Month: <*Answer_7771*>|\n| Method/Plan/Intent in Past Month: <*Answer_7772*>|\n| Suicidal Behavior: <*Answer_7773*>||\n| KEY INDICATORS:\n
\n\n"], ["154", "WHODAS2.0-12\n", "\n| | World Health Organization Disability Assessment Schedule 2.0 - \n Questions and Answers: | \n S1. Standing for long periods such as 30 minutes?| <*Answer_7810*>| \n S2. Taking care of your household responsibilities?|\n <*Answer_7811*>| S3. Learning a new task, for example, learning how\n to get to a new place? | <*Answer_7812*>| S4. How much of a\n problem did you have joining in community activities (for example,\n festivities, religious or other activities) in the same way\n as anyone else can?| <*Answer_7813*>| S5. How much have you\n been emotionally affected by your health problems? | \n<*Answer_7814*>| S6. Concentrating on doing something for ten\n12-item (WHODAS2.0-12) | |\n minutes?| <*Answer_7815*>| S7. Walking a long distance such as a\n kilometer (or equivalent)?| <*Answer_7816*>| S8.\n Washing your whole body?| <*Answer_7817*>| S9. Getting dressed?|\n <*Answer_7818*>| S10. Dealing with people you do not know?| \n <*Answer_7819*>| S11. Maintaining a friendship?|\n <*Answer_7820*>|\n S12. Your day-to-day work?| <*Answer_7821*>|\n| |Information contained in this note is based on a self-report \nassessment and is not sufficient to use alone for diagnostic purposes.\n Assessment results should be verified for accuracy and used in\n Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.> |\n conjunction with other diagnostic activities.\n| |Copyright World Health Organization. 2009. All Rights Reserved. \nMeasuring health and disability: manual for WHO Disability Assessment\n Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva. $~\n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.> | | | \n GLOBAL DISABILITY SCORE: <*Answer_7771*>| Scores range from 0-48, with\n higher scores indicating more severe disability.\n| |\n
\n\n"], ["155", "PC-PTSD-5+I9\n", "\n| | PC-PTSD-5+PHQ Item9 (PC-PTSD-5+I9)\n| PC PTSD-5+I9 PTSD Screen: <*Answer_7776*>| <*Answer_7771*>|<*Answer_7772*>|\n| PC PTSD-5+I9 Suicide Screen: <*Answer_7777*>| <*Answer_7773*>|<*Answer_7774*>| |\n \nQuestions and Answers|\n \n Sometimes things happen to people that are unusually or especially| \n frightening, horrible, or traumatic. For example:||\n A serious accident or fire|\n A physical or sexual assault or abuse|\n An earthquake or flood|\n| Date Given: <.Date_Given.>\n A war|\n Seeing someone be killed or seriously injured|\n Having a loved one die through homicide or suicide||\n Have you ever experienced this kind of event?| <*Answer_7822*>||\n \n 1. Had nightmares about the event(s) when you did not want to?| <*Answer_7823*>|\n 2. Tried hard not to think about the event(s) or went out of your way to|\n avoid situations that remind you of the event(s)?| <*Answer_7824*>|\n 3. Been constantly on guard, watchful, or easily startled?| <*Answer_7825*>|\n 4. Felt numb or detached from people, activities, or your surroundings?| <*Answer_7826*>|\n| Clinician: <.Staff_Ordered_By.>\n 5. Felt guilty or unable to stop blaming yourself or others for the|\n event(s) or any problems the event(s) may have caused?| <*Answer_7828*>|\n 6. Over the last 2 weeks, how often have you been bothered by thoughts |\n that you would be better off dead or of hurting yourself in some way?| <*Answer_7829*>|\n \n| |Information contained in this note is based on a self-report assessment and\n|is not sufficient to use alone for diagnostic purposes. Assessment results\n|should be verified for accuracy and used in conjunction with other diagnostic\n|activities and procedures.\n \n| Location: <.Location.>\n| |PC-PTSD-5, 2015, National Center for PTSD\n \n$~\n| | Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| |\n \n
\n\n"], ["156", "BPRS-A\n", "\n|.|.| Brief Psychiatric Rating Scale- Anchored (BPRS-A) | \n \n TOTAL PATHOLOGY SCORE: <*Answer_7775*>||\nQuestions and Answers| |\n1. Somatic Concern - Degree of concern over present bodily health is perceived as problem by the patient, whether the complaints have a realistic basis or not. Do not rate mere reporting of somatic symptoms. Rate only concerns for (or worrying a\nbout) physical problems (real or imagined).| <*Answer_7831*>| |\n \n2. Anxiety - Worry, fear, or over concern for present or future. Rate solely on the basis of verbal report of the patient's own subjective experiences. Do not infer anxiety from physical signs or from neurotic defense mechanisms. Do not rate if \nrestricted to somatic concern. | <*Answer_7832*> | |\n \n3. Emotional Withdrawal - Deficiency in relating to the interviewer and to the interview situation. \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \nOvert manifestations of this deficiency include poor/absence of eye contact, failure to orient \noneself physically toward the interviewer, and a general lack of involvement or engagement in the \ninterview. Distinguish from BLUNTED AFFECT, in which deficits in facial expression, body gesture, \nand voice pattern are scored. [DO NOT SELECT Severe or Very Severe IF EXPLAINED BY \nDISORIENTATION] | <*Answer_7833*> | |\n \n4. Conceptual Disorganization - Degree of speech incomprehensibility. Include any type of formal thought disorder (e.g., loose associations, incoherence, flight of ideas, neologisms). DO NOT include mere circumstantiality or pressured speech,\n even if marked. DO NOT rate on the patient's subjective impressions (e.g., "My thoughts are racing", "I can't hold a thought", "My thinking gets all mixed up"). Rate ONLY on the basis of observations made during the interview.| <*Answer_7834*>\n| |\n \nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n5. Guilt Feelings - Overconcern or remorse for past behavior. Rate on patient's subjective experiences of guilt as evidenced by verbal report. Do not infer guilt feelings from depression, anxiety, or neurotic defenses. | <*Answer_7835*>| |\n \n6. Tension - Rate motor restlessness (agitation) observed during the interview. DO NOT rate on the basis of subjective experiences reported by the patient. Disregard suspected pathogenesis (e.g., tardive dyskinesia).| <*Answer_7836*> | |\n \n7. Mannerisms And Posturing - Unusual and unnatural motor behavior. Rate only abnormality of movements; do not rate simple heightened motor activity here. Consider frequency, duration, and degree of bizarreness. Disregard suspected pathogenesis.\n| <*Answer_7837*> | |\n \n8. Grandiosity - Inflated self-esteem (self-confidence), or inflated appraisal of one's talents, powers, abilities, accomplishments, knowledge, importance, or identity. Do not score mere grandiose quality of claims (e.g., "I'm the worst sinner i\nn the world," "The entire country is trying to kill me") unless the guilt/persecution is related to some special exaggerated attribute of the individual. Also, the patient must claim exaggerated attributes: e.g., If patient denies talents, power\ns, etc., even if he/she states that others indicate that he/she has these attributes, this item should not be scored.| <*Answer_7838*> | |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n \n9. Depressive Mood - Subjective report of feeling depressed, blue "down in the dumps," etc. Rate only the degree of reported depression. Do not rate on the basis of inferences concerning depression based upon general retardation and somatic\n complaints. | <*Answer_7839*> | |\n \n10. Hostility - Animosity, contempt, belligerence, disdain for other people outside the interview situation. Rate solely on the basis of the verbal report of feelings and actions of the patient toward others. Do not infer hostility from neurotic\n defenses, anxiety, or somatic complaints. |<*Answer_7840*> | |\n \n11. Suspiciousness - Belief (delusional or otherwise) that others have now, or have had in the past, malicious or discriminatory intent toward the patient. On the basis of verbal report, rate only those suspicions which are currently held\n whether they concern past or present circumstance.| <*Answer_7841*> | |\n \n| Gender: <.Patient_Gender.>| | |\n12. Hallucinatory Behavior - Perceptions (in any sense modality) in absence of identifiable external stimulus. Rate only experiences that have occurred during the last week. DO NOT rate "voices in my head" or "visions in my mind" unless the\n patient can differentiate between these experiences and his or her thoughts.|<*Answer_7842*> | |\n \n13. Motor Retardation - Reduction in energy level evidenced in slowed movements. Rate on the basis of observed behavior of the patient only. Do not rate on the basis of the patient's subjective impression of his or her own energy level.\n| <*Answer_7843*> | |\n \n14. Uncooperativeness - Evidence of resistance, unfriendliness, resentment, and lack of readiness to cooperate with the interviewer. Rate solely on the basis of the patient's attitude and responses to the interviewer and the interview situation.\n Do not rate on the basis of reported resentment or uncooperativeness outside the interview situation. |<*Answer_7844*> | |\n \n15. Unusual Thought Content - Severity of delusions of any type - consider conviction and effect on actions. Assume full conviction if patient has acted on his or her beliefs.| <*Answer_7845*>| |\n Thinking Disturbance (S) : <*Answer_7771*>|\n \n16. Blunted Affect - Diminished affective responsivity, as characterized by deficits in facial expression, body gesture, and voice pattern. Distinguish from EMOTIONAL WITHDRAWAL, in which the focus is on interpersonal impairment rather that\n affect. Consider degree and consistency of impairment.| <*Answer_7846*> | |\n \n17. Excitement - Heightened emotional tone, including irritability and expansiveness (Hypomanic affect). Do not infer affect from statements of grandiose delusions.|<*Answer_7847*> | |\n \n18. Disorientation - Confusion Or Lack Of Proper Association For Person, Place Or Time.| <*Answer_7848*> | |\n \nInformation 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. | |\n \n Anxious Depression (D) : <*Answer_7772*>|\nCopyright 2014, CDISC, all rights reserved.\n$~ \n Paranoid Disturbances (P) : <*Answer_7773*>|\n Withdrawal Retardation (R): <*Answer_7774*>||\n
\n\n"], ["157", "PSS-3 2ND\n", "\n|.|.| Patient Safety Secondary Screener: (PSS-3 2nd)|\n <*Answer_7772*>|\n <*Answer_7773*>|\n <*Answer_7774*>|\n <*Answer_7775*>|\n <*Answer_7776*>|\n <*Answer_7777*>| |\n \nQuestions and Answers:| 1. Did the patient screen positive on both PSS \nitems - active Ideation with a past attempt?| <*Answer_7849*>|\n 2. Has the individual begun a suicide plan?| <*Answer_7850*>|\n | Date Given: <.Date_Given.>| Clinician:<.Staff_Ordered_By.>| Location: <.Location.>\n 3. Has the individual recently had intent to act on his/her ideation?| \n<*Answer_7851*>|\n 4. Has the patient ever had a psychiatric hospitalization?| \n<*Answer_7852*>|\n 5. Does the patient have a pattern of excessive substance use?| \n<*Answer_7853*>|\n 6. Is the patient irritable, agitated, or aggressive?| <*Answer_7854*>| |\n \n|<*Answer_7778*>| \n | | \n | | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\nInformation contained in this note is based on a self-report \n|assessment and is not sufficient to use alone for diagnostic purposes. \n|Assessment results should be verified for accuracy and used in \n|conjunction with other diagnostic activities.| |\nCopyright 2015, Boudreaux, E. Reproduced with permission| | $~\n | Gender:<.Patient_Gender.>|| |\n \n<*Answer_7780*>|<*Answer_7781*>|<*Answer_7782*> | |\n \nPOSITIVE INDICATORS|\n <*Answer_7771*>|\n
\n\n"], ["158", "PCL-5 WEEKLY\n", "\n PCL-5 WEEKLY\n| Gender: <.Patient_Gender.>\n|\n|\n| PCL-5 Weekly Score: <-PCL-5->\n|\n| This measure assesses an individual's perception of the distress associated\n| with possible PTSD symptoms. It is not used to diagnose PTSD. Symptoms are\n| rated from 0-4 in terms of distress they cause the individual. Scores that\n| are greater than or equal to 31-33 suggest that the veteran may meet the\n| criteria for a PTSD diagnosis. However, it is important to use caution when\n|\n| using this cutoff since it is possible for some Veterans with scores lower\n| than 31-33 to meet criteria for PTSD.\n|\n| Additional testing using a structured diagnostic interview, such as the\n| Clinician Administered PTSD Scale for DSM-5, is recommended to confirm\n| diagnostic status.\n|\n| Values range from 0 to 80 with higher scores indicating more probable PTSD.\n|\n|\n| Date Given: <.Date_Given.>\n| Questions and Answers:\n|\n| 1. Repeated, disturbing, and unwanted memories of the stressful experience?\n| <*Answer_7855*>\n| 2. Repeated, disturbing dreams of the stressful experience?\n| <*Answer_7856*>\n| 3. Suddenly feeling or acting as if the stressful experience were actually\n| happening again (as if you were actually back there reliving it)?\n| <*Answer_7857*>\n| 4. Feeling very upset when something reminded you of the stressful\n| Clinician: <.Staff_Ordered_By.>\n| experience?\n| <*Answer_7858*>\n| 5. Having strong physical reactions when something reminded you of the\n| stressful experience (for example, heart pounding, trouble breathing,\n| sweating)?\n| <*Answer_7859*>\n| 6. Avoiding memories, thoughts, or feelings related to the stressful\n| experience?\n| <*Answer_7860*>\n| 7. Avoiding external reminders of the stressful experience (for example,\n| Location: <.Location.>\n| people, places, conversations, activities, objects, or situations)?\n| <*Answer_7861*>\n| 8. Trouble remembering important parts of the stressful experience?\n| <*Answer_7862*>\n| 9. Having strong negative beliefs about yourself, other people, or the\n| world (for example, having thoughts such as: I am bad, there is\n| something seriously wrong with me, no one can be trusted, the world is\n| completely dangerous)?\n| <*Answer_7863*>\n| 10. Blaming yourself or someone else for the stressful experience or what\n|\n| happened after it?\n| <*Answer_7864*>\n| 11. Having strong negative feelings such as fear, horror, anger, guilt, or\n| shame?\n| <*Answer_7865*>\n| 12. Loss of interest in activities that you used to enjoy?\n| <*Answer_7866*>\n| 13. Feeling distant or cut off from other people?\n| <*Answer_7867*>\n| 14. Trouble experiencing positive feelings (for example, being unable to\n| Veteran: <.Patient_Name_Last_First.>\n| feel happiness or have loving feelings for people close to you)?\n| <*Answer_7868*>\n| 15. Irritable behavior, angry outbursts, or acting aggressively?\n| <*Answer_7869*>\n| 16. Taking too many risks or doing things that could cause you harm?\n| <*Answer_7870*>\n| 17. Being "superalert" or watchful or on guard?\n| <*Answer_7871*>\n| 18. Feeling jumpy or easily startled?\n| <*Answer_7872*>\n| SSN: <.Patient_SSN.>\n| 19. Having difficulty concentrating?\n| <*Answer_7873*>\n| 20. Trouble falling or staying asleep?\n| <*Answer_7874*>\n|\n| Information contained in this note is based on a self-report assessment and is not sufficient\n to use alone for diagnostic purposes. Assessment results should be verified for accuracy and\n used in conjunction with other diagnostic activities and procedures.\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["159", "HSI\n", "\n|.|.|Heaviness of Smoking Index (HSI) |\n|1-2 = Low dependence\n|3-4 = Moderate dependence\n|5-6 = High dependence| |\n \n<*Answer_7772*>| \n<*Answer_7773*>|\n<*Answer_7774*>|\n \n|(Question and Answers)|\n1. How soon after you wake up do you smoke/use your first \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \ncigarette/chew?|<*Answer_7875*>| |\n2. How many cigarettes do you smoke in a day?|<*Answer_7876*>| |\n \nAdapted with permission: The Fagerstrom Test for Nicotine Dependence: a \nrevision of the Fagerstrom Tolerance Questionnaire, by T. F. Heatherton, \nL. et al., 1991 British Journal of Addiction, 86(9).| |\n \nHeatherton, T. F., et al. (1989). Measuring the heaviness of smoking: \nUsing self-reported time to the first cigarette of the day and number of \ncigarettes smoked per day. Addiction, 84, 791-800.| |\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n \nInformation 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. $~\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| \n \n|<*Answer_7771*> | |\n|RANGE OF SCORES\n|0 = No dependence\n
\n\n"], ["16", "PAS-EQUIP\n", "\n.|.|Enhancing Quality of Care in Psychosis||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nyour doctor for mental health problems?| <*Answer_4429*>|26. Do you know the names of your medications that you are prescribed?| <*Answer_4430*>|27. Here is a list of medications you may be \nprescribed. Check all of the medications that you are currently prescribed.| <*Answer_4431*>|28. Over the past month, to what extent have you taken the medications prescribed by your doctor for \nmental health problems?| <*Answer_4432*>|29. What is your height: How many feet?| <*Answer_4433*>|How many inches:| <*Answer_4434*>|30. What is your weight in pounds?| <*Answer_4435*>|31. \nHave you been weighing yourself every week at home?| <*Answer_4436*>|32. Over the past month, have you gained or lost weight or stayed the same?| <*Answer_4437*>|33. How much weight have you \ngained?| <*Answer_4438*>|34. How much weight have you lost?| <*Answer_4439*>|35. Has your doctor recently talked with you about changing to medication that does not cause weight gain?| \n<*Answer_4440*>|36. Has your doctor recently recommended that you go to wellness or weight loss groups?| <*Answer_4441*>|37. How many times in the past month did you attend wellness or weight loss \ngroups?| <*Answer_4442*>|39. Have you changed your diet in order to lose weight?| <*Answer_4443*>|40. Have you increased your physical activity recently in order to lose weight?| \n<*Answer_4444*>|41. Have you ever had angina, a heart attack, or a stroke?| <*Answer_4445*>|42. Do you currently have diabetes or hypertension, or are you being treated for diabetes or \nhypertension?| <*Answer_4455*>|43. Are you currently working in a job for pay?| <*Answer_4446*>|44. How many weeks have you worked at this job?| <*Answer_4447*>|45. How many hours a week do \nyou usually work?| <*Answer_4448*>|46. Is this a job that anyone can apply for, or is it only for disabled people?| <*Answer_4449*>|47. How many dollars did you earn last month?| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Questions and Answers||1. Managing your day-to-day life?| <*Answer_4405*>|2. Coping with problems in your life?| \n<*Answer_4450*>|48. Is this the total gross income from the job, or the amount of take-home pay from the job?| <*Answer_4456*>|49. Would you be interested in working at a paying job if it would \nnot affect your benefits too much and you could get the support you need?| <*Answer_4451*>|50. Has your doctor recently recommended that you go to the VA's work program---called "IPS" or \n"supported employment" ?| <*Answer_4452*>|51. How many times in the past month did you attend the VA's work program called IPS or supported employment?| <*Answer_4453*>|52. During the past \nmonth, how many job interviews have you gone to?| <*Answer_4454*>| |Information contained in this note is based on a self report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities. $~\n<*Answer_4406*>|3. Concentrating?| <*Answer_4407*>|4. Get along with people in your family?| <*Answer_4408*>|5. Get along with people outside your family?| <*Answer_4409*>|6. Get along well \nin social situations?| <*Answer_4410*>|7. Feel close to another person?| <*Answer_4411*>|8. Feel like you had someone to turn to if you needed help?| <*Answer_4412*>|9. Feel confident in \nyourself?| <*Answer_4413*>|10. Feel sad or depressed?| <*Answer_4414*>|11. Think about ending your life?| <*Answer_4415*>|12. Feel nervous?| <*Answer_4416*>|13. Have thoughts racing \nthrough your head?| <*Answer_4417*>|14. Think you had special powers?| <*Answer_4418*>|15. Hear voices or see things?| <*Answer_4419*>|16. Think people were watching you?| \n<*Answer_4420*>|17. Think people were against you?| <*Answer_4421*>|18. Have mood swings?| <*Answer_4422*>|19. Feel short-tempered?| <*Answer_4423*>|20. Think about hurting yourself?| \n<*Answer_4424*>|21. Did you have an urge to drink alcohol or take street drugs?| <*Answer_4425*>|22. Did anyone talk to you about your drinking or drug use?| <*Answer_4426*>|23. Did you try to \nhide your drinking or drug use?| <*Answer_4427*>|24. Did you have problems from your drinking or drug use?| <*Answer_4428*>|25. Over the past month have you been prescribed any medication by \n
\n\n"], ["160", "WEMWBS\n", "\n|.|.|Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) |\n \nQuestions and Answers| |\n1. I've been feeling optimistic about the future. |<*Answer_7877*>|\n2. I've been feeling useful. |<*Answer_7878*>|\n3. I've been feeling relaxed.|<*Answer_7879*>|\n4. I've been feeling interested in other people.|<*Answer_7880*>|\n5. I've had energy to spare.|<*Answer_7881*>|\n6. I've been dealing with problems well.|<*Answer_7882*>|\n7. I've been thinking clearly.|<*Answer_7883*>|\n8. I've been feeling good about myself.|<*Answer_7884*>|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n9. I've been feeling close to other people.|<*Answer_7885*>|\n10. I've been feeling confident.|<*Answer_7886*>|\n11. I've been able to make up my own mind about things.|<*Answer_7887*>|\n12. I've been feeling loved.|<*Answer_7888*>|\n13. I've been interested in new things.|<*Answer_7889*>|\n14. I've been feeling cheerful.|<*Answer_7890*>| | |\n \nInformation contained in this note is based on a self-report assessment \nand is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with \nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nother diagnostic activities.| |\n \nWarwick-Endinburgh Mental Well-Being Scale (WEMWBS)NHS Health Scotland,\nUniversity of Warwick and University of Edinburgh, 2006, All rights \nreserved. Reproduced with permission.| | $~\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>|\n \n|<*Answer_7771*> | |\n \nTotal scores range from a minimum of 14 to a maximum of 70, change scores of 3 or more points suggest a significant difference. Scores equal to or less than 40 are consistent with a high-risk category for mental illness.| |\n
\n\n"], ["161", "MHRM\n", "\n|.|.|Mental Health Recovery Measure (MHRM) |\n Self-Empowerment: <*Answer_7773*> |\n Learning and Self-Redefinition: <*Answer_7774*> |\n Basic Functioning: <*Answer_7775*> |\n Overall Well-Being: <*Answer_7776*> |\n New Potentials: <*Answer_7777*> |\n Spirituality: <*Answer_7778*> |\n Advocacy/Enrichment: <*Answer_7779*> | |\n \nMHRM Total Scores can range from 0 to 120. Higher scores correspond to a higher self-reported level of mental health recovery. The average score for mental health consumers range from 78-80, with a change score of 10 points representing signifi\ncant individual change. | |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n \nMHRM subscale scores can range from 0 to 16 for each subscale except the Spirituality subscale, which can range from 0 to 8. | |\n \nNote: Results with more than 4 omitted items OR with a Total Score of "0" (all "Strongly Disagree") or a Total Score of "120" (all "Strongly Agree") are of questionable validity and should be interpreted with caution. | |\n \nQuestion and Answers:|\n1. I work hard toward my mental health recovery.|<*Answer_7891*>|\n2. Even though there are hard days, things are improving for me.|<*Answer_7892*>|\n3. I ask for help when I am not feeling well.|<*Answer_7893*>|\n4. I take risks to move forward with my recovery.|<*Answer_7894*>|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n5. I believe in myself.|<*Answer_7895*>|\n6. I have control over my mental health problems.|<*Answer_7896*>|\n7. I am in control of my life.|<*Answer_7897*>|\n8. I socialize and make friends.|<*Answer_7898*>|\n9. Every day is a new opportunity for learning.|<*Answer_7899*>|\n10. I still grow and change in positive ways despite my mental health problems.|<*Answer_7900*>|\n11. Even though I may still have problems, I value myself as a person of worth.| <*Answer_7901*>|\n12. I understand myself and have a good sense of who I am.|<*Answer_7902*>|\n13. I eat nutritious meals every day.|<*Answer_7903*>|\n14. I go out and participate in enjoyable activities every week.|<*Answer_7904*>|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n15. I make the effort to get to know other people.|<*Answer_7905*>|\n16. I am comfortable with my use of prescribed medications.|<*Answer_7906*>|\n17. I feel good about myself.|<*Answer_7907*>|\n18. The way I think about things helps me to achieve my goals.|<*Answer_7908*>|\n19. My life is pretty normal.|<*Answer_7909*>|\n20. I feel at peace with myself.|<*Answer_7910*>|\n21. I maintain a positive attitude for weeks at a time.|<*Answer_7911*>|\n22. My quality of life will get better in the future.|<*Answer_7912*>|\n23. Every day that I get up, I do something productive.|<*Answer_7913*>|\n24. I am making progress towards my goals.|<*Answer_7914*>|\n| Gender: <.Patient_Gender.>| | |\n25. When I am feeling low, my religious faith or spirituality helps me feel better.|<*Answer_7915*>|\n26. My religious faith or spirituality supports my recovery.|<*Answer_7916*>|\n27. I advocate for the rights of myself and others with mental health problems.|<*Answer_7917*>|\n28. I engage in work or other activities that enrich myself and the world around me.|<*Answer_7918*>|\n29. I cope effectively with stigma associated with having a mental health problem.|<*Answer_7919*>|\n30. I have enough money to spend on extra things or activities that enrich my life.|<*Answer_7920*>| |\n \nInformation 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.| |\n \nThe MHRM2003, Young, SL and Bullock, WA. Available from the University of Toledo, Department of Psychology.|\n \n$~\nMHRM Total Score: <*Answer_7771*>|\n MHRM Subscales Scores: |\n Overcoming Stuckness: <*Answer_7772*> |\n
\n\n"], ["162", "AD8\n", "\n|Ascertain Dementia 8-item Informant Questionnaire (AD8)|\n|AD8 Screening scores range from 0-8, with scores in the 0-1 range suggesting\n|"NORMAL COGNITION" and scores 2 or greater suggesting "COGNITIVE IMPAIRMENT IS\n|LIKELY TO BE PRESENT."\n||Note: Scores in the impaired range indicate a need for further diagnostic\n|assessment. Scores in the "normal" range suggest that a dementing disorder\n|is unlikely, but a very early disease process cannot be ruled out.|\n|Question and Answers:|\n| 1. Problems with judgement (e.g., problems making decisions, bad financial\n| decisions, problems with thinking)\n| <*Answer_7926*>\n| Date Given: <.Date_Given.>\n| 2. Less interest in hobbies/activities\n| <*Answer_7927*>\n| 3. Repeats the same things over and over (questions, stories, or statements)\n| <*Answer_7928*>\n| 4. Trouble learning how to use a tool, appliance, or gadget (e.g., VCR,\n| computer, microwave, remote control)\n| <*Answer_7929*>\n| 5. Forgets correct month or year\n| <*Answer_7930*>\n| 6. Trouble handling complicated financial affairs (e.g., balancing\n| Clinician: <.Staff_Ordered_By.> \n| checkbook, income taxes, paying bills)\n| <*Answer_7931*>\n| 7. Trouble remembering appointments\n| <*Answer_7932*>\n| 8. Daily problems with thinking and/or memory\n| <*Answer_7933*>\n| \n|Copyright 2005. The AD8 is a copyrighted instrument of the Knight Alzheimer\n|Disease Research Center, Washington University, St. Louis, Missouri.\n|All Rights Reserved. Reproduced with permission|\n| Location: <.Location.>| \n|Information contained in this note is based on a self-report assessment\n|and is not sufficient to use alone for diagnostic purposes. Assessment\n|results should be verified for accuracy and used in conjunction with\n|other diagnostic activities.\n| Veteran: <.Patient_Name_Last_First.> \n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| \n|AD8 Dementia Rating Score: <-AD8 TOTAL->, suggesting <*Answer_7771*>|\n
\n\n"], ["163", "EPDS\n", "\n|.|.|Edinburgh Postnatal Depression Scale (EPDS) |\nTotal scores range from a minimum of 0 to a maximum of 30. Mothers who score above 10 are likely to be suffering from a depressive illness of varying severity. A careful clinical assessment should be carried out to \nconfirm the diagnosis. The scale indicates how the mother has felt during the previous week.\n \n||Questions and Answers\n|1. I have been able to laugh and see the funny side of things|\n<*Answer_7934*>\n|2. I have looked forward with enjoyment to things|\n<*Answer_7935*>\n|3. I have blamed myself unnecessarily when things went wrong|\n<*Answer_7936*>\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n|4. I have been anxious or worried for no good reason|\n<*Answer_7937*>\n|5. I have felt scared or panicky for no very good reason|\n<*Answer_7938*>\n|6. Things have been getting on top of me|\n<*Answer_7939*>\n|7. I have been so unhappy that I have had difficulty sleeping|\n<*Answer_7940*>\n|8. I have felt sad or miserable|\n<*Answer_7941*>\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n|9. I have been so unhappy that I have been crying|\n<*Answer_7942*>\n|10. The thought of harming myself has occurred to me |\n<*Answer_7943*>| |\n \n \nInformation contained in this note is based on a self-report assessment \nand is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with \nother diagnostic activities.| |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n \nUsers may reproduce the scale without further permission providing they \nrespect copyright by quoting the names of the authors, the title and the \nsource of the paper in all reproduced copies. | $~\n| Gender: <.Patient_Gender.>| |\n \nPostnatal Depression Score: <-TOTAL POSTNATAL DEPRESSION->| |\n<*Answer_7771*>|\n<*Answer_7772*>| |\n
\n\n"], ["164", "CES\n", "\n|.|.|Combat Exposure Scale (CES) |\n| 1 = 0-8 light\n| 2 = 9-16 light - moderate\n| 3 = 17-24 moderate\n| 4 = 25-32 moderate - heavy\n| 5 = 33-41 heavy| |\n \n \nQuestions and Answers:|\n| 1. Did you ever go on combat patrols or have other dangerous duty?| <*Answer_7944*>|\n| 2. Were you ever under enemy fire?| <*Answer_7945*>|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n| 3. Were you ever surrounded by the enemy?| <*Answer_7946*>|\n| 4. What percentage of the soldiers in your unit were killed (KIA), wounded| or missing in action (MIA)?| <*Answer_7947*>|\n| 5. How often did you fire rounds at the enemy?| <*Answer_7948*>|\n| 6. How often did you see someone hit by incoming or outgoing rounds?| <*Answer_7949*>|\n| 7. How often were you in danger of being injured or killed (i.e., being| pinned down, overrun, ambushed, near miss, etc.)?| <*Answer_7950*>|| |\n \nInformation contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities.| |\n \nCopyright 1989, National Center for PTSD|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n \n$~\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| |\n \n<*Answer_7772*>| | \nThe total exposure to combat score can be categorized according to the | \nfollowing scale:\n
\n\n"], ["165", "FTND\n", "\n|.|.|Fagerstrm Test for Nicotine Dependence (FTND) |\n 0-2 = Very low dependence|\n 3-4 = Low dependence|\n 5 = Medium dependence|\n 6-7 = High dependence|\n 8-10 = Very high dependence| |\n \n \nQuestions and Answers| |\n1. How soon after you wake up do you smoke/use your first cigarette/chew?|\n <*Answer_7951*>| |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n2. Do you smoke/chew more frequently in the hours after waking than \nduring the| rest of the day?|\n <*Answer_7952*>| |\n3. Do you find it difficult not to smoke/chew?|\n <*Answer_7953*>| |\n4. Which cigarette/chew would be the hardest to give up?|\n <*Answer_7954*>| |\n5. How many cigarettes do you smoke in a day?|\n <*Answer_7955*>| |\n6. Do you smoke when you're so sick that you're home in bed?|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n <*Answer_7956*>| |\n \n \n \nInformation contained in this note is based on a self-report assessment| \nand is not sufficient to use alone for diagnostic purposes. Assessment| \nresults should be verified for accuracy and used in conjunction with| \nother diagnostic activities.| |\n \nAdapted with permission: The Fagerstrm Test for Nicotine Dependence: a| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\nrevision of the Fagerstrm Tolerance Questionnaire, by T. F. Heatherton,|\n L. et al., 1991, British Journal of Addiction, 86(9).|\n \n \n \n$~\n| Gender: <.Patient_Gender.>| |\n \nNICOTINE DEPENDENCE SCORE: <*Answer_7771*>| |\n \nRANGE OF SCORES| \n
\n\n"], ["166", "BASIS-24 PSYCHOSIS\n", "\n|.|.|Behavior and Symptom Identification Scale 24 - Psychosis Sxs(BASIS-24 PSYCHOSIS) | | Date Given: <.Date_Given.>| Clinician:\n \n Questions and Answers: ||\n 1. Think you had special powers?| <*Answer_7957*>|\n 2. Hear voices or see things?| <*Answer_7958*>|\n 3. Think people were watching you?| <*Answer_7959*>|\n 4. Think people were against you?| <*Answer_7960*>|\n| |Copyright 2011, McLean Hospital. Reproduced with permission.\n \n| |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.\n $~\n<.Staff_Ordered_By.>| Location: <.Location.>| | Veteran:\n<.Patient_Name_Last_First.>| SSN:<.Patient_SSN.>| DOB:\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>) | Gender:\n<.Patient_Gender.>| | \n<*Answer_999999999999*>||\n \nPsychotic Symptoms scores range from 0 to 4 with higher scores reflecting|\nhigher levels or reported psychotic symptoms.| |\n
\n\n"], ["167", "MPI-PAIN-INTRF\n", "\n|.|.|WHYMPI Pain Interference Scale (MPI-PAIN-INTRF) |\n greater interference. | |\n \nQuestion and Answers:| | \n1. In general, how much does your pain problem interfere with your day to|\n day activities? |\n <*Answer_7961*>| |\n \n2a. Are you retired from work for reasons other than your pain problem? |\n <*Answer_7962*>| |\n \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n2. Since the time you developed a pain problem, how much has your pain|\n changed your ability to work? |\n <*Answer_7963*>| |\n \n3. How much has your pain changed the amount of satisfaction or enjoyment you |\n get from participating in social and creational activities?|\n <*Answer_7964*>| |\n \n4. How much has your pain changed your ability to participate in recreational|\n and other social activities? |\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n <*Answer_7965*>| |\n \n5. How much has your pain changed the amount of satisfaction you get from|\n family-related activities? |\n <*Answer_7966*>| |\n \n6. How much has your pain changed your marriage and other family|\n relationships? |\n <*Answer_7967*>| |\n7a. Are you currently working? |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n <*Answer_7968*>| |\n \n7. How much has your pain changed the amount of satisfaction or enjoyment|\n you get from work? |\n <*Answer_7969*>| |\n \n8. How much has your pain changed your ability to do household chores? |\n <*Answer_7970*>| |\n \n9. How much has your pain changed your friendships with people other than|\n| Gender: <.Patient_Gender.>| |\n your family? |\n <*Answer_7971*>| |\n \nInformation contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities.\n \n| |Copyright 1985, Robert D. Kerns, Dennis C. Turk, and Thomas E. Rudy\n \n$~\n \nPain Interference: <*Answer_999999999999*> | |\n \nPain interference scores range from 0 to 6 with higher scores reflecting |\n
\n\n"], ["168", "IJSS\n", "\n|.|.|Indiana Job Satisfaction Scale (IJSS)|\n| Pay: <*Answer_7772*>\n| Advancement and Security: <*Answer_7773*>\n| Supervision: <*Answer_7774*>\n| Co-Workers: <*Answer_7775*>\n| How I Feel on this Job: <*Answer_7776*>\n| Total Mean Score: <*Answer_7777*>| |\n \nScale and Mean scores range from 1-VERY DISSATISFIED to 4-VERY SATISFIED,| with:|\n 1 = Very Dissatisfied|\n 2 = Dissatisfied|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n 3 = Satisfied|\n 4 = Very Satisfied| |\n \nQuestions and Answers:| |\n \n1. I feel good about this job.| \n <*Answer_7972*>| |\n2. This job is worthwhile.|\n <*Answer_7973*>| |\n3. The working conditions are good.|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n <*Answer_7974*>| |\n4. I want to quit this job.|\n <*Answer_7975*>| |\n5. This job is boring.|\n <*Answer_7976*>| |\n6. I am happy about the amount of money that this job pays.|\n <*Answer_7977*>| |\n7. The vacation time and other benefits are okay.|\n <*Answer_7978*>| |\n8. I need more money than this job pays.|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n <*Answer_7979*>| |\n9. This job does not provide the medical coverage I need.|\n <*Answer_7980*>| |\n10. I have a fairly good chance for promotion in this job.|\n <*Answer_7981*>| |\n11. This is a dead-end job.|\n <*Answer_7982*>| |\n12. I feel that there is a good chance of my losing this job in the \nfuture.|\n <*Answer_7983*>| |\n| Gender: <.Patient_Gender.>| |\n13. My supervisor is fair.|\n <*Answer_7984*>| |\n14. My supervisor is hard to please.|\n <*Answer_7985*>| |\n15. My supervisor praises me when I do my job well.|\n <*Answer_7986*>| |\n16. My supervisor is difficult to get along with.|\n <*Answer_7987*>| |\n17. My supervisor recognizes my efforts.|\n <*Answer_7988*>| |\n \n18. My co-workers are easy to get along with.|\n <*Answer_7989*>| |\n19. My co-workers are lazy.|\n <*Answer_7990*>| |\n20. My co-workers are unpleasant.|\n <*Answer_7991*>| |\n21. My co-workers don't like me.|\n <*Answer_7992*>| |\n22. My co-workers help me to like this job more.|\n <*Answer_7993*>| |\n \n23. I have a co-worker I can rely on.|\n <*Answer_7994*>| |\n24. I have a co-worker I consider a friend.|\n <*Answer_7995*>| |\n25. I look forward to coming to work.|\n <*Answer_7996*>| |\n26. I often feel tense on the job.|\n <*Answer_7997*>| |\n27. I don't know what's expected of me on this job.|\n <*Answer_7998*>| |\nScale & Mean Score\n28. I feel physically worn out at the end of the day.|\n <*Answer_7999*>| |\n29. Working makes me feel like I'm needed.|\n <*Answer_8000*>| |\n30. My job keeps me busy.|\n <*Answer_8001*>| |\n31. I get to do a lot of different things on my job.|\n <*Answer_8002*>| |\n32. I am satisfied with my schedule.|\n <*Answer_8003*>| |\n| General Satisfaction: <*Answer_7771*>\n \nInformation contained in this note is based on a self-report assessment \nand is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with \nother diagnostic activities.||\n \n$~\n
\n\n"], ["169", "I9+C-SSRS\n", "\n|PHQ-Item 9 + Columbia Suicide Severity Rating Scale (I9+C-SSRS) ||\n|<*Answer_7772*>\n|<*Answer_7773*>|\n|SCREENING INDICATORS:\n|<*Answer_7774*>\n|<*Answer_7777*>\n|<*Answer_7778*>|\nQuestions and Answers: ||\n 1. Over the past 2 weeks, how often have you had thoughts that you would be better off dead or of hurting yourself in some way?| <*Answer_8004*>|\n 2. Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?| <*Answer_8005*>|\n 3. Over the past month, have you had any actual thoughts of killing yourself?| <*Answer_8006*>|\nDate Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.> |\n 4. Over the past month, have you been thinking about how you might do this?| <*Answer_8007*>|\n 5. Over the past month, have you had these thoughts and had some intention of acting on them? | <*Answer_8008*>|\n 6. Over the past month, have you started to work out or worked out the details of how to kill yourself?| <*Answer_8009*>|\n 7. If yes, at any time in the past month did you intend to carry out this plan?| <*Answer_8010*>|\n 8. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life (for example, collected pills, obtained a gun, gave away valuables, went to the roof but didn't jump)?| <*Answer_8011*>|\n 9. If yes, was this within the past 3 months?| <*Answer_8012*> ||\n| |Columbia-Suicide Severity Rating Scale (C-SSRS) 2016 The Columbia Lighthouse Project. Scale may be reproduced without permission.\n| |Information contained in this note is based on a self-report\n assessment and is not sufficient to use alone for diagnostic purposes.\n Assessment results should be verified for accuracy and used in\nLocation: <.Location.>| |Veteran: <.Patient_Name_Last_First.>|\n conjunction with other diagnostic activities. $~\nSSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n|Gender: <.Patient_Gender.> |\n|PRIMARY SUICIDE RISK SCREEN (PHQ-I9)|\nThe results of this administration indicate a <*Answer_7775*> primary screen for risk of suicide over the past two weeks.|\n|<*Answer_7776*>\n|<*Answer_7771*>\n
\n\n"], ["17", "PAS-EQUIP\n", ""], ["170", "MCMI4\n", "\n|.|.|MCMI-IV (Millon Clinical Multiaxial Inventory-IV) |\nINVALIDITY(V)= <*Answer_7773*>|\nINCONSISTENCY (W)= <*Answer_7774*>||\nValidity Score \n Profile of BR Scores|\n 0 35\n 75 100|\nModifying Indices Raw BR Low \n Average High|\n<*Answer_7775*>|\nPersonality Score \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \nProfile of BR Scores|\n 0 \n 60 75 85 115|\nClinical Personality Patterns Raw PR BR \n Style Type Disorder|\n<*Answer_7776*>|\nSevere Personality Pathology|\n<*Answer_7777*>|\nPsychopathology Score \nProfile of BR Scores|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n 0 \n 60 75 85 115|\nClinical Syndromes Raw PR BR \n Present Prominent|\n<*Answer_7778*>|\nSevere Clinical Syndromes|\n<*Answer_7779*>|\n FACET SCALES FOR HIGHEST ELEVATED PERSONALITY SCALES|\n FACET SCALES Score \nProfile for BR Scores|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n 0 35\n 75 100|\n Raw PR BR \n Interpretable|\n<*Answer_7780*>|\n|\n GROSSMAN FACET SCALE SCORES|\n Raw PR BR|\n<*Answer_7781*>|\nNOTEWORTHY RESPONSES|\n| Gender: <.Patient_Gender.>|\nThe patient answered the following statements in the direction noted in|\nparentheses. These items suggest specific problem areas that the|\nclinician may wish to investigate.||\n<*Answer_7782*>|\nEnd of Report|\nNOTE: This and previous pages of this report contain trade secrets and|\nare not to be released in response to requests under HIPAA (or any other|\ndata disclosure law that exempts trade secret information from release).|\nFurther, release in response to litigation discovery demands should be|\nmade only in accordance with your profession's ethical guidelines and|\n|\nunder an appropriate protective order.|\n<*Answer_7784*>|\n|\nInformation contained in this note is based on a self-report assessment \nand is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with \nother diagnostic activities.||\nCopyright 2015 DICANDRIEN, Inc. All rights reserved. MCMI and Millon \nare registered trademarks of DICANDRIEN, Inc.|\n$~\n<*Answer_7783*>|\nHIGH-POINT CODE= <*Answer_7771*>|\nBR ADJUSTMENTS= <*Answer_7772*>|\n
\n\n"], ["171", "Q-LES-Q-SF\n", "\n |.|.|Quality of Life Enjoyment and Satisfaction Questionnaire - Short\nSelf-Rating of Overall Satisfaction (Item 16)*: <*Answer_7772*>| |\n \n*Note: All scores reflect respondent satisfaction ratings for "during the \npast week."| |\nQuestions and Answers | |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n1. Your physical health?|\n <*Answer_8211*>| |\nTaking everything into consideration, during the last week how satisfied \n Form (Q-LES-Q-SF) |\nhave you been with:|\n2. Your mood?|\n <*Answer_8212*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n3. Your work?|\n <*Answer_8213*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n4. Your household activities?|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|\n <*Answer_8214*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n5. Your social relationships?|\n <*Answer_8215*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n6. Your family relationships?|\n <*Answer_8216*>| |\nTaking everything into consideration, during the past week how satisfied \n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|\nhave you been with:|\n7. Your leisure time activities?|\n <*Answer_8217*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n8. Your ability to function in daily life?|\n <*Answer_8218*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n9. Your sexual drive, interest and/or performance?|\n SSN: <.Patient_SSN.>|\n <*Answer_8219*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n10. Your economic status?|\n <*Answer_8220*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n11. Your living/housing situation?|\n <*Answer_8221*>| |\nTaking everything into consideration, during the last week how satisfied \n DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|\nhave you been with:|\n12. Your ability to get around physically without feeling dizzy or|\n unsteady or falling?|\n <*Answer_8222*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n13. Your vision in terms of ability to do work or hobbies?|\n <*Answer_8223*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n Gender: <.Patient_Gender.>| |\n14. Your overall sense of well-being?|\n <*Answer_8224*>| |\nTaking everything into consideration, during the past week how satisfied \nhave you been with:|\n15. Your medication?|\n <*Answer_8225*>| |\nTaking everything into consideration, during the last week how satisfied \nhave you been with:|\n16. How would you rate your overall life satisfaction and contentment \nduring the past week?|\nQuality of Life/Life Enjoyment Percent of Max Score*: <*Answer_7779*>%|\n <*Answer_8226*>| |\n Information contained in this note is based on a self-report assessment|\nand is not sufficient to use alone for diagnostic purposes. Assessment|\nresults should be verified for accuracy and used in conjunction with|\nother diagnostic activities.| |\n The Q-LES-Q-SF is copyrighted by Jean Endicott, Ph.D. Permission granted|\nto electronically reproduce for clinicians use and research in|\nnon-industry studies. For other uses, contact copyright holder.| |\n \n$~\nSatisfaction with Medications (Item 15)*: <*Answer_7771*> |\n
\n\n"], ["172", "BBHI-2\n", "\n.| ******Brief Battery for Health Improvement 2 (BBHI-2)******||\nValidity:|\n| 38. My physical problems really don't bother me that much.| <*Answer_8264*>|\n| 39. I protect my health by staying at home.| <*Answer_8265*>|\n| 40. My pain never changes.| <*Answer_8266*>|\n| 41. I feel well enough to work.| <*Answer_8267*>|\n| 42. I'm afraid that my poor health will ruin my most important relationships.| <*Answer_8268*>|\n| 43. There are many jobs that I am capable of doing.| <*Answer_8269*>|\n| 44. My life is full and satisfying.| <*Answer_8270*>|\n| 45. I am afraid of pushing myself too hard.| <*Answer_8271*>|\n| 46. With my kind of problems, there's little hope of getting better.| <*Answer_8272*>|\n| 47. This has been one of the worst times of my life.| <*Answer_8273*>|\n<*Answer_7771*>|\n| 48. I get so restless at times that I can't stand still.| <*Answer_8274*>|\n| 49. My life used to be much better than it is now.| <*Answer_8275*>|\n| 50. I am allergic to the glass found in jars.| <*Answer_8276*>|\n| 51. I am afraid that my physical problems might kill me.| <*Answer_8277*>|\n| 52. Lately, I have been thinking about suicide a lot.| <*Answer_8278*>|\n| 53. I am content with my life.| <*Answer_8279*>|\n| 54. I fear being struck down by an attack of some illness.| <*Answer_8280*>|\n| 55. My life seems like one defeat after another.| <*Answer_8281*>|\n| 56. My health problems really aren't that serious.| <*Answer_8282*>|\n| 57. When I think about my physical problems, I get depressed.| <*Answer_8283*>|\nPAIN COMPLAINTS (0-10 ANALOG PAIN SCALE)|\n| 58. My life shouldn't be this hard.| <*Answer_8284*>|\n| 59. I often get depressed; it's like I fall in a hole and can't get out.| <*Answer_8285*>|\n| 60. I have many severe problems that come and go.| <*Answer_8286*>|\n| 61. There are many things I won't do for fear of hurting myself.| <*Answer_8287*>|\n| 62. Recently my life has been a nightmare.| <*Answer_8288*>|\n| 63. I'm often afraid that something bad will happen to me.| <*Answer_8289*>|||\nInformation contained in this note is based on a self-report assessment and is not sufficient to use|\nalone for diagnostic purposes. Assessment results should be verified for accuracy and used in|\nconjunction with other diagnostic activities.||\nCopyright 2002 NCS Pearson, Inc. All rights reserved.|\n<*Answer_7787*>|\nPearson, the PSI Design, PsychCorp, and BBHI are trademarks in the US and/or other countries, of|\nPearson Education, Inc., or its affiliates.|\n| $~\nPAIN DIMENSIONS Pt <*Answer_7791*> Median for|\n Median* Community**|\n Highest in the Past Month:<*Answer_7788*> 8 4|\n Lowest in the Past Month: <*Answer_7789*>|\n Maximum Tolerable Pain: <*Answer_7790*>|\n Pain Range: <*Answer_7773*>|\n Date Given: <.Date_Given.>|\n Peak Pain: <*Answer_7774*>|\n Pain Tolerance: <*Answer_7775*>|\n Overall Pain at Testing: <*Answer_7772*>|\n|\nThe pain ratings above are based on the patient's highest pain level in the past month and|\nare ranked on a scale of 0 to 10 (0 = No pain, 10 = Worst pain imaginable). The degree to|\nwhich the patient's pain reports are consistent with objective medical findings should be|\nconsidered. Diffuse pain reports, a nonanatomic distribution of pain, or a pattern of pain|\nthat is inconsistent with the reports of patients with a similar diagnosis increases the|\nrisk that psychological factors are influencing his pain reports.||\n Clinician: <.Staff_Ordered_By.>|\n*Based on a sample of <*Answer_7792*>.|\n**Based on a community sample of over 700 individuals.||\nPATIENT SCALE SCORES, NORMS AND PROFILE|\n--------------------------------------|\nScale Raw Pt-T Com-T Profile|\n-----Validity Scale---------------- 10 40 50 60 90|\n<*Answer_7777*>|\n-----Physical Symptom Scales------- :....:....:|\n<*Answer_7778*>|\n<*Answer_7779*>|\n Location: <.Location.>| |\n<*Answer_7780*>|\n-----Affective Scales-------------- :....:....:|\n<*Answer_7781*>|\n<*Answer_7782*>||\nNotes on Interpreting the Profile: The T-Score Profile plots T scores based on both patient|\nand community norms. Approximately 68% of the samples scored in the average range of 40 to|\n60. Scores above or below this range are clinically significant. The longer the bar, the|\nmore significantly [V 1.0] the score deviates from the mean. One value outside the average|\nrange is significant. Both values outside is more significant.||\nSCALE RATING Percentile (Based on T-Score)|\n Veteran: <.Patient_Name_Last_First.>|\n<*Answer_7783*>||\nCRITICAL ITEMS/AREAS|\n<*Answer_7784*>||\nOMITTED ITEMS|\n<*Answer_7785*>||\nRANDOM RESPONDING CHECK|\n<*Answer_7786*>||\n|Questions and Answers|\n| 0. Please select the primary area where you have pain: (this question is REQUIRED)| <*Answer_8402*>|\n| 1. Head (headache pain)?| <*Answer_8227*>|\n SSN: <.Patient_SSN.>|\n| 2. Jaw or face?| <*Answer_8228*>|\n| 3. Neck or shoulders?| <*Answer_8229*>|\n| 4. Arms or hands?| <*Answer_8230*>|\n| 5. Chest?| <*Answer_8231*>|\n| 6. Abdomen or stomach?| <*Answer_8232*>|\n| 7. Middle back?| <*Answer_8233*>|\n| 8. Lower back?| <*Answer_8234*>|\n| 9. Genital area?| <*Answer_8235*>|\n| 10. Legs or feet?| <*Answer_8236*>|\n| 11. Taking into account all the parts of your body that hurt, what was your overall highest level|\n DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|\nof pain during the past month?| <*Answer_8237*>|\n| 12. Taking into account all the parts of your body that hurt, what was your overall lowest level of|\npain during the past month?| <*Answer_8238*>|\n| 13. Taking into account all the parts of your body that hurt, what is your overall level of pain|\nright now?| <*Answer_8239*>|\n| 14. Taking into account all the parts of your body that hurt, what level of pain could you tolerate|\nand still work and get on with your life?| <*Answer_8240*>|\n| 15. Feeling exhausted but being unable to sleep?| <*Answer_8241*>|\n| 16. Irritability?| <*Answer_8242*>|\n| 17. Shakiness or jitters?| <*Answer_8243*>|\n Gender: <.Patient_Gender.>||\n| 18. Being unable to relax?| <*Answer_8244*>|\n| 19. Feeling that nothing seems real?| <*Answer_8245*>|\n| 20. Lump in throat/difficulty swallowing?| <*Answer_8246*>|\n| 21. Pounding or racing heart when not exerting yourself?| <*Answer_8247*>|\n| 22. Hearing voices that other people don't hear?| <*Answer_8248*>|\n| 23. Feeling bloated or gassy?| <*Answer_8249*>|\n| 24. Lack of interest in sex?| <*Answer_8250*>|\n| 25. Difficulty concentrating?| <*Answer_8251*>|\n| 26. I am satisfied with the medical care I am receiving.| <*Answer_8252*>|\n| 27. I am barely able to keep up with my work.| <*Answer_8253*>|\nRESULTS|\n| 28. I worry about becoming dependent on prescription medication.| <*Answer_8254*>|\n| 29. I walk and move very carefully so I won't cause myself pain.| <*Answer_8255*>|\n| 30. Things have been terrible at home lately.| <*Answer_8256*>|\n| 31. I've had no problems with sleeping.| <*Answer_8257*>|\n| 32. I am not disabled.| <*Answer_8258*>|\n| 33. I have never abused alcohol or drugs.| <*Answer_8259*>|\n| 34. I can't work.| <*Answer_8260*>|\n| 35. Somebody owes me for all of my pain and suffering.| <*Answer_8261*>|\n| 36. Pain would not stop me from doing my favorite things.| <*Answer_8262*>|\n| 37. I am very angry with one or more of my doctors.| <*Answer_8263*>|\n
\n\n"], ["173", "PROMIS29\n", "\n|.|.|Patient Reported Outcome Measurement Information System (PROMIS) 29 Profile v1.0 |\nAnxiety <*Answer_7772*> <*Answer_7779*>|\nDepression <*Answer_7773*> <*Answer_7780*>|\nFatigue <*Answer_7774*> <*Answer_7781*>|\nSleep Disturbance <*Answer_7775*> <*Answer_7782*>|\nSatisfaction with Social Role <*Answer_7776*> <*Answer_7783*>|\nPain Interference <*Answer_7777*> <*Answer_7784*>|\nPain Intensity <*Answer_8318*> N/A | |\n \n \n \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \nQuestions and Answers| |1. Physical Functioning: Are you able to do\n chores such as vacuuming or yard work?|\n <*Answer_8290*>| |\n2. Physical Functioning: Are you able to go up and down stairs at a normal pace?|\n <*Answer_8291*>| |\n3. Physical Functioning: Are you able to go for a walk of at least 15 minutes?|\n <*Answer_8292*>| |\n4. Physical Functioning: Are you able to run errands and shop?|\n <*Answer_8293*>| |\n5. Anxiety: IN THE PAST 7 DAYS I felt fearful.|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n <*Answer_8294*>| |\n6. Anxiety: IN THE PAST 7 DAYS I found it hard to focus on anything other than\n my anxiety.|\n <*Answer_8295*>| |\n7. Anxiety: IN THE PAST 7 DAYS my worries overwhelmed me.|\n <*Answer_8296*>| |\n8. Anxiety: IN THE PAST 7 DAYS I felt uneasy.| \n <*Answer_8297*>| |\n9. Depression: IN THE PAST 7 DAYS I felt worthless.|\n <*Answer_8298*>| |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n10. Depression: IN THE PAST 7 DAYS I felt helpless.|\n <*Answer_8299*>| |\n11. Depression: IN THE PAST 7 DAYS I felt depressed.|\n <*Answer_8300*>| |\n12. Depression: IN THE PAST 7 DAYS I felt hopeless.|\n <*Answer_8301*>| |\n13. Fatigue: DURING THE PAST 7 DAYS I feel fatigued.|\n <*Answer_8302*>| |\n14. Fatigue: DURING THE PAST 7 DAYS I have trouble STARTING things because I\n am tired.| \n| Gender: <.Patient_Gender.>| |\n <*Answer_8303*>| |\n15. Fatigue: IN THE PAST 7 DAYS - How run down did you feel on average?|\n <*Answer_8304*>| |\n16. Fatigue: IN THE PAST 7 DAYS - How fatigued were you on average?|\n <*Answer_8305*>| |\n17. Sleep Disturbance: IN THE PAST 7 DAYS my sleep quality was,|\n <*Answer_8306*>| |\n18. Sleep Disturbance: IN THE PAST 7 DAYS my sleep was refreshing,|\n <*Answer_8307*>| |\n19. Sleep Disturbance: IN THE PAST 7 DAYS I had a problem with sleep,|\n \n <*Answer_8308*>| |\n20. Sleep Disturbance: IN THE PAST 7 DAYS I had difficulty falling asleep,|\n <*Answer_8309*>| |\n21. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with how\n much work I can do (include work at home).|\n <*Answer_8310*>| |\n22. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\n ability to work (include work at home).|\n <*Answer_8311*>| |\n23. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\n \n ability to do regular personal and household responsibilities.|\n <*Answer_8312*>| |\n24. Satisfaction with Social Role: IN THE PAST 7 DAYS I am satisfied with my\n ability to perform my daily routines.|\n <*Answer_8313*>| |\n25. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere in your day to day \nactivities?|\n <*Answer_8314*>| |\n26. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere \n with your work around the house?|\nTOTALS Raw Score T-Score| |\n <*Answer_8315*>| |\n27. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere with\n your ability to participate in social activities?|\n <*Answer_8316*>| |\n28. Pain Interference: IN THE PAST 7 DAYS - How much did pain interfere with\n your household chores?|\n <*Answer_8317*>| |\n29. Pain Intensity: How would you rate your pain on average?| \n <*Answer_8318*>| |\n \nPhysical Function <*Answer_7771*> <*Answer_7778*>|\n \nInformation contained in this note is based on a self-report assessment \nand is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with \nother diagnostic activities.| |\n \n 2008-2016 PROMIS Health Organization and PROMIS Cooperative Group\n \n$~\n
\n\n"], ["174", "ISS-2\n", "\n|.|.|Internal State Scale - Version 2 (ISS-2) | |\n \nNote: Though clinically relevant ranges or cut-off scores have not been \nestablished, Activation, Depression and Perceived Conflict subscales may\n be used to measure symptom severity within or across individuals.| |\n \nQuestions and answers| |\n1. Today my mood is changeable.|\n <*Answer_8319*>| |\n2. Today I feel irritable.|\n <*Answer_8320*>| |\n Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n3. Today I feel like a capable person.|\n <*Answer_8321*>| |\n4. Today I feel like people are out to get me.|\n <*Answer_8322*>| |\n5. Today I actually feel great inside.| \n <*Answer_8323*>| |\n6. Today I feel impulsive.|\n <*Answer_8324*>| |\n7. Today I feel depressed.|\n <*Answer_8325*>| |\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n8. Today my thoughts are going fast.|\n <*Answer_8326*>| |\n9. Today it seems like nothing will ever work out for me.|\n <*Answer_8327*>| |\n10. Today I feel overactive.|\n <*Answer_8328*>| |\n11. Today I feel as if the world is against me.|\n <*Answer_8329*>| |\n12. Today I feel "sped up" inside.|\n <*Answer_8330*>| |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|\n13. Today I feel restless.|\n <*Answer_8331*>| |\n14. Today I feel argumentative.|\n <*Answer_8332*>| |\n15. Today I feel energized.|\n <*Answer_8333*>| |\n16. Today I feel.|\n <*Answer_8334*>| |\n \nInformation contained in this note is based on a self-report assessment \n Gender: <.Patient_Gender.>| |\nand is not sufficient to use alone for diagnostic purposes. Assessment\n results should be verified for accuracy and used in conjunction with\n other diagnostic activities.| |\n \nUsed with permission of the author\n \n$~\n \n<*Answer_999999999999*> | |\n \nThe combination of scores on Activation and Well Being scales are consistent with a <*Answer_7776*> mood state.| |\n
\n\n"], ["175", "IMRS\n", "\n.|.|Illness Management and Recovery Scales (IMRS) - Client Self-Rating|\n| Questions and Answers|\n| 1. Progress towards personal goals: In the past 3 months, I have come up with. \n| <*Answer_8335*>\n| 2. Knowledge: How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication? \n| <*Answer_8336*>\n| 3. Involvement of family and friends in my mental health treatment: How much are family members, friends, boyfriend/girlfriend, and other people who are important to you (outside your mental health agency) involved in your mental health \ntreatment? \n| <*Answer_8337*>\n| 4. Contact with people outside of my family: In a normal week, how many times do you talk to someone outside of your family (like a friend, co-worker, classmate, roommate, etc.) \n| <*Answer_8338*>\n| Date Given: <.Date_Given.>\n| 5. Time in structured roles: How much time do you spend working, volunteering, being a student, being a parent, taking care of someone else or someone else's house or apartment? That is, how much time do you spend in doing activities for or \nwith another person that are expected of you? (This would not include selfcare or personal home maintenance.) \n| <*Answer_8339*>\n| 6. Symptom distress: How much do your symptoms bother you? \n| <*Answer_8340*>\n| 7. Impairment of functioning: How much do your symptoms get in the way of you doing things that you would like to or need to do? \n| <*Answer_8341*>\n| 8. Relapse prevention planning: Which of the following would best describe what you know and what you have done in order not to have a relapse? \n| <*Answer_8342*>\n| 9. Relapse of symptoms: When is the last time you had a relapse of symptoms (that is, when your symptoms have gotten much worse)? \n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8343*>\n| 10. Psychiatric hospitalizations: When is the last time you have been hospitalized for mental health or substance abuse reasons? \n| <*Answer_8344*>\n| 11. Coping: How well do feel like you are coping with your mental or emotional illness from day to day? \n| <*Answer_8345*>\n| 12. Involvement with self-help activities: How involved are you in consumer run services, peer support groups, Alcoholics Anonymous, drop-in centers, WRAP (Wellness Recovery Action Plan), or other similar self-help programs? \n| <*Answer_8346*>\n| 13. Using medication effectively: (Don't answer this question if your doctor has not prescribed medication for you). How often do you take your medication as prescribed? \n| <*Answer_8347*>\n| 14. Functioning affected by alcohol use: Drinking can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, to difficulty showing up at appointments or paying attention during \n| Location: <.Location.>|\nthem, or to increased symptoms. Over the past 3 months, how much did drinking get in the way of your functioning? \n| <*Answer_8348*>\n| 15. Functioning affected by drug use: Using street drugs, and misusing prescription or over-the-counter medication can interfere with functioning when it contributes to conflict in relationships, or to money, housing and legal concerns, to \ndifficulty showing up at appointments or paying attention during them, or to increased symptoms. Over the past 3 months, how much did drug use get in the way of your functioning? \n| <*Answer_8349*>|||\n|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.\n| $~\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>|\n|<*Answer_999999999999*>|\n
\n\n"], ["176", "COPD\n", "\n .| |COPD Assessment Test (CAT)||\n <*Answer_7772*>||\n3. Rate the tightness of your chest: 0 - My chest does not feel tight at all TO 5 - My chest feels very tight|\n <*Answer_7773*>||\n4. Rate your breathlessness: 0 - When I walk up a hill or one flight of stairs I am not breathless TO 5 - When I walk up a hill or one flight of stairs I am very breathless|\n <*Answer_7774*>||\n5. Rate your activity limitation: 0 - I am not limited doing any activities at home TO 5 - I am very limited doing activities at home|\n <*Answer_7775*>||\n6. Rate your confidence: 0 - I am confident leaving my home despite my lung condition TO 5 - I am not at all confident leaving my home because of my lung condition|\n <*Answer_7776*>||\n7. Rate your sleep: 0 - I sleep soundly TO 5 - I don't sleep soundly because of my lung condition|\n Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>||\n <*Answer_7777*>||\n8. Rate your energy: 0 - I have lots of energy TO 5 - I have no energy at all|\n <*Answer_7778*>||\nInformation 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.||\nCopyright 2009 GlaxoSmithKline group of companies.||\n| $~\n Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | \nCAT TOTAL SCORE = <*Answer_7779*>||\nTotal scores range from 0-40. Higher scores indicate a more severe impact of COPD on a patient's life. Scores <10 have a low impact, 10-20 medium, 21-30 high and >30 very high impact, requiring gradually more interventions.|||\nQuestions and Answers||\n1. Rate your cough: 0 - I never cough TO 5 - I cough all the time|\n <*Answer_7771*>||\n2. Rate your phlegm: 0 - I have no phlegm (mucus) in my chest at all TO 5 - My chest is completely fully of phlegm (mucus)|\n
\n\n"], ["177", "CSDD-RS\n", "\n|.|.|Cornell Scale for Depression in Dementia - Response Sheet (CSDD-RS) |\nScores above 18 indicate a definite major depression.|\nScores above 10 indicate a probable major depression.|\nScores below 6 as a rule are associated with absence of significant depressive symptoms.| | \n \nQuestions and Answers:|\n|\n1. MOOD-RELATED SIGNS: Anxiety; anxious expression, rumination, worrying|\n <*Answer_8358*>| |\n2. MOOD-RELATED SIGNS: Sadness; sad expression, sad voice, tearfulness|\n <*Answer_8359*>| |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n3. MOOD-RELATED SIGNS: Lack of reaction to pleasant events|\n <*Answer_8360*>| |\n4. MOOD-RELATED SIGNS: Irritability; annoyed, short tempered|\n <*Answer_8361*>| |\n5. BEHAVIORAL DISTURBANCE: Agitation; restlessness, hand wringing, hair pulling|\n <*Answer_8362*>| |\n6. BEHAVIORAL DISTURBANCE: Retardation; slow movements, slow speech,\n slow reactions|\n <*Answer_8363*>| |\n7. BEHAVIORAL DISTURBANCE: Multiple physical complaints \n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n(score 0 if gastrointestinal symptoms only)|\n <*Answer_8364*>| |\n8. BEHAVIORAL DISTURBANCE: Loss of interest; less involved in usual activities\n (score 0 only if change occurred acutely, i.e., in less than one month)|\n <*Answer_8365*>| |\n9. PHYSICAL SIGNS: Appetite loss; eating less than usual|\n <*Answer_8366*>| |\n10. PHYSICAL SIGNS: Weight loss (score 2 if greater than 5 pounds in one month)|\n <*Answer_8367*>| |\n11. PHYSICAL SIGNS: Lack of energy; fatigues easily, unable to sustain\n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n activities|\n <*Answer_8368*>| |\n12. CYCLIC FUNCTIONS: Diurnal variation of mood; symptoms worse in the morning|\n <*Answer_8369*>| |\n13. CYCLIC FUNCTIONS: Difficulty falling asleep; later than usual for this \nindividual|\n <*Answer_8370*>| |\n14. CYCLIC FUNCTIONS: Multiple awakenings during sleep|\n <*Answer_8371*>| |\n15. CYCLIC FUNCTIONS: Early morning awakening; earlier than usual for this\n | Gender: <.Patient_Gender.>||\n individual|\n <*Answer_8372*>| |\n16. IDEATIONAL DISTURBANCE: Suicidal; feels life is not worth living|\n <*Answer_8373*>| |\n17. IDEATIONAL DISTURBANCE: Poor self-esteem; self-blame, self-depreciation,\n feelings of failure|\n <*Answer_8374*>| |\n18. IDEATIONAL DISTURBANCE: Pessimism; anticipation of the worst|\n <*Answer_8375*>| |\n19. IDEATIONAL DISTURBANCE: Mood congruent delusions; delusions of poverty,\n \n illness or loss|\n <*Answer_8376*>| |\n \nNOTES/CURRENT MEDICATIONS: <*Answer_8377*> | |\n \nInformation contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other \ndiagnostic activities.| |\n \n$~\n \n \nCSDD-RS Total Score = <*Answer_7771*>| |\n
\n\n"], ["178", "RAID\n", "\n.| Rating Anxiety In Dementia - (RAID)| |\nRAID TOTAL SCORE = <*Answer_999999999999*>||\nA score of 11 or more suggests significant clinical anxiety.|||\nQuestions and Answers||\n 1. Worry: Worry about physical health.|\n <*Answer_8382*>||\n 2. Worry: Worry about cognitive performance (failing memory, getting lost when out, not able to follow conversation).|\n <*Answer_8383*>||\n 3. Worry: Worry over finances, family problems, physical health of relatives.|\n <*Answer_8384*>||\n 4. Worry: Worry associated with false belief and/or perception.|\n Date Given: <.Date_Given.>|\n <*Answer_8385*>||\n 5. Worry: Worry over trifles (repeatedly calling for attention over trivial matters).|\n <*Answer_8386*>||\n 6. Apprehension and Vigilance: Frightened and anxious (keyed up and on the edge).|\n <*Answer_8387*>||\n 7. Apprehension and Vigilance: Sensitivity to noise (exaggerated startle response).|\n <*Answer_8388*>||\n 8. Apprehension and Vigilance: Sleep disturbance (trouble with falling or staying asleep).|\n <*Answer_8389*>||\n 9. Apprehension and Vigilance: Irritability (more easily annoyed than usual, short tempered and angry outbursts).|\n Clinician: <.Staff_Ordered_By.>|\n <*Answer_8390*>||\n10. Motor Tension: Trembling.|\n <*Answer_8391*>||\n11. Motor Tension: Motor tension (complain of headache, other body aches and pains).|\n <*Answer_8392*>||\n12. Motor Tension: Restlessness (fidgeting, cannot sit still, pacing, wringing hands, picking clothes).|\n <*Answer_8393*>||\n13. Motor Tension: Fatigability, tiredness.|\n <*Answer_8394*>||\n14. Autonomic Hypersensitivity: Palpitations (complains of heart racing or thumping).|\n Location: <.Location.>| |\n <*Answer_8395*>||\n15. Autonomic Hypersensitivity: Dry mouth (not due to medication) sinking feeling in the stomach.|\n <*Answer_8396*>||\n16. Autonomic Hypersensitivity: Hyperventilating, shortness of breath (even when not exerting).|\n <*Answer_8397*>||\n17. Autonomic Hypersensitivity: Dizziness or light-headedness (complains as if going to faint).|\n <*Answer_8398*>||\n18. Autonomic Hypersensitivity: Sweating, flushes or chills, tingling or numbness of fingers and toes.|\n <*Answer_8399*>||\nPhobias: (Fears which are excessive, that do not make sense and tends to avoid - like afraid of crowds, going out alone, being in a small room, or being frightened by some kind of animals, heights, etc.).|\n Veteran: <.Patient_Name_Last_First.>|\nDescribe:|\n <*Answer_8400*>||\nPanic attacks: (Feelings of anxiety or dread that are so strong that they think they are going to die or have a heart attack and they simply have to do something to stop them, like immediately leaving the place, phoning relatives, etc.).|\nDescribe:|\n <*Answer_8401*>||\nInformation 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.||\n $~\n SSN: <.Patient_SSN.>|\n DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|\n Gender: <.Patient_Gender.>||\nStatus at Evaluation: <*Answer_8380*> <*Answer_8381*>|||\n
\n\n"], ["179", "SWEMWBS\n", "\n|.|.|The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)| |\n indicating greater overall mental well-being.| |\n Questions and Answers:| |\n 1. I've been feeling optimistic about the future.|\n <*Answer_8403*> ||\n 2. I've been feeling useful.|\n <*Answer_8404*> ||\n 3. I've been feeling relaxed.|\n <*Answer_8405*> ||\n 4. I've been dealing with problems well.|\n <*Answer_8406*> ||\n \n 5. I've been thinking clearly.|\n <*Answer_8407*> ||\n 6. I've been feeling close to other people.|\n <*Answer_8408*> ||\n 7. I've been able to make up my own mind about things.|\n <*Answer_8409*> |||\nShort Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) NHS Health|\nScotland, University of Warwick and University of Edinburgh, 2007, all rights|\nreserved.| |\nInformation contained in this note is based on a self-report assessment and|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \nis not sufficient to use alone for diagnostic purposes. Assessment results|\nshould be verified for accuracy and used in conjunction with other diagnostic|\nactivities.| |\n$~\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| |\n SWEMWBS Total Metric Score: <-METRIC SCORE->| |\n Total scores range from a minimum of 7 to a maximum of 35, with higher\n scores|\n
\n\n"], ["18", "PAS-EQUIP\n", "\n|Enhancing Quality of Care in Psychosis||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nyour doctor for mental health problems?| <*Answer_4429*>|26.Do you know the names of your medications that you are prescribed?| <*Answer_4430*>|27.Here is a list of medications you may be \nprescribed. Check all of the medications that you are currently prescribed.| <*Answer_4431*>|28.Over the past month, to what extent have you taken the medications prescribed by your doctor for \nmental health problems?| <*Answer_4432*>|29.What is your height: How many feet?| <*Answer_4433*>|How many inches:| <*Answer_4434*>|30.What is your weight in pounds?| \n<*Answer_4435*>|31.Have you been weighing yourself every week at home?| <*Answer_4436*>|32.Over the past month, have you gained or lost weight or stayed the same?| <*Answer_4437*>|33.How \nmuch weight have you gained?| <*Answer_4438*>|34.How much weight have you lost?| <*Answer_4439*>|35.Has your doctor recently talked with you about changing to medication that does not cause \nweight gain?| <*Answer_4440*>|36.Has your doctor recently recommended that you go to wellness or weight loss groups?| <*Answer_4441*>|37.How many times in the past month did you attend \nwellness or weight loss groups?| <*Answer_4442*>|39.Have you changed your diet in order to lose weight?| <*Answer_4443*>|40.Have you increased your physical activity recently in order to lose \nweight?| <*Answer_4444*>|41.Have you ever had angina, a heart attack, or a stroke?| <*Answer_4445*>|42.Do you currently have diabetes or hypertension, or are you being treated for diabetes or \nhypertension?| <*Answer_4455*>|43.Are you currently working in a job for pay?| <*Answer_4446*>|44.How many weeks have you worked at this job?| <*Answer_4447*>|45.How many hours a week do \nyou usually work?| <*Answer_4448*>|46.Is this a job that anyone can apply for, or is it only for disabled people?| <*Answer_4449*>|47.How many dollars did you earn last month?| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1.Managing your day-to-day life?| <*Answer_4405*>|2.Coping with problems in your life?| \n<*Answer_4450*>|48.Is this the total gross income from the job, or the amount of take-home pay from the job?| <*Answer_4456*>|49.Would you be interested in working at a paying job if it would \nnot affect your benefits too much and you could get the support you need?| <*Answer_4451*>|50.Has your doctor recently recommended that you go to the VA's work program---called "IPS" or \n"supported employment" ?| <*Answer_4452*>|51.How many times in the past month did you attend the VA's work program called IPS or supported employment?| <*Answer_4453*>|52.During the past \nmonth, how many job interviews have you gone to?| <*Answer_4454*>| $~\n<*Answer_4406*>|3.Concentrating?| <*Answer_4407*>|4.Get along with people in your family?| <*Answer_4408*>|5.Get along with people outside your family?| <*Answer_4409*>|6.Get along well \nin social situations?| <*Answer_4410*>|7.Feel close to another person?| <*Answer_4411*>|8.Feel like you had someone to turn to if you needed help?| <*Answer_4412*>|9.Feel confident in \nyourself?| <*Answer_4413*>|10.Feel sad or depressed?| <*Answer_4414*>|11.Think about ending your life?| <*Answer_4415*>|12.Feel nervous?| <*Answer_4416*>|13.Have thoughts racing \nthrough your head?| <*Answer_4417*>|14.Think you had special powers?| <*Answer_4418*>|15.Hear voices or see things?| <*Answer_4419*>|16.Think people were watching you?| \n<*Answer_4420*>|17.Think people were against you?| <*Answer_4421*>|18.Have mood swings?| <*Answer_4422*>|19.Feel short-tempered?| <*Answer_4423*>|20.Think about hurting yourself?| \n<*Answer_4424*>|21.Did you have an urge to drink alcohol or take street drugs?| <*Answer_4425*>|22.Did anyone talk to you about your drinking or drug use?| <*Answer_4426*>|23.Did you try to \nhide your drinking or drug use?| <*Answer_4427*>|24.Did you have problems from your drinking or drug use?| <*Answer_4428*>|25.Over the past month have you been prescribed any medication by \n
\n\n"], ["180", "MHRM-10\n", "\n|.|.|Mental Health Recovery Measure-10 (MHRM-10)|\nQuestions and Answers:| |\n \n 1. I still grow and change in positive ways despite my mental health problem.|\n <*Answer_8410*>| |\n \n 2. Even though I may still have problems, I value myself as a person of worth.|\n <*Answer_8411*>| |\n \n 3. I understand myself and have a good sense of who I am.|\n <*Answer_8412*>| |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n \n 4. I feel good about myself.|\n <*Answer_8413*>| |\n \n 5. The way I think about things helps me to achieve my goals.|\n <*Answer_8414*>| |\n \n 6. I feel at peace with myself.|\n <*Answer_8415*>| |\n \nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n 7. I maintain a positive attitude for weeks at a time.|\n <*Answer_8416*>| |\n \n 8. Every day that I get up, I do something productive.|\n <*Answer_8417*>| |\n \n 9. I am making progress toward my goals.|\n <*Answer_8418*>| |\n \n10. I engage in work or other activities that enrich myself and the world around me.|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n <*Answer_8419*>| |\n \n \nInformation 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.\n \n| $~\n| Gender: <.Patient_Gender.>| |\n \nMHRM-10 Total Score: <-TOTAL SCORE->|\n MHRM-10 scores range from 0 to 40, with higher scores indicating higher perceived mental health recovery.| |\n \n
\n\n"], ["181", "EAT-26\n", "\nEating Attitudes Test-26 Item (EAT-26) |\n \nBehavioral alerts present = <*Answer_7773*>| |\n \nA score at or above 20 on the EAT-26 indicates a high level of concern | \nabout dieting, body weight or problematic eating behaviors.| |\n \nQuestions and Answers:| |\n \nPart B:||\n \n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n 1. Am terrified about being overweight.| <*Answer_8420*>| |\n 2. Avoid eating when I am hungry.| <*Answer_8421*>| |\n 3. Find myself preoccupied with food.| <*Answer_8422*>| |\n 4. Have gone on eating binges where I feel that I may not be able to stop.| <*Answer_8423*>| |\n 5. Cut my food into small pieces.| <*Answer_8424*>| |\n 6. Aware of the calorie content of food that I eat.| <*Answer_8425*>| |\n 7. Particularly avoid food with a high carbohydrate content (i.e., bread,|\n rice, potatoes, etc.).| <*Answer_8426*>| |\n 8. Feel that others would prefer if I ate more.| <*Answer_8427*>| |\n 9. Vomit after I have eaten.| <*Answer_8428*>| |\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n 10. Feel extremely guilty after eating.| <*Answer_8429*>| |\n 11. Am preoccupied with a desire to be thinner.| <*Answer_8430*>| |\n 12. Think about burning up calories when I exercise.| <*Answer_8431*>| |\n 13. Other people think that I am too thin.| <*Answer_8432*>| |\n 14. Am preoccupied with the thought of having fat on my body.| <*Answer_8433*>| |\n 15. Take longer than others to eat my meals.| <*Answer_8434*>| |\n 16. Avoid foods with sugar in them.| <*Answer_8435*>| |\n 17. Eat diet foods.| <*Answer_8436*>| |\n 18. Feel that food controls my life.| <*Answer_8437*>| |\n 19. Display self-control around food.| <*Answer_8438*>| |\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n 20. Feel that others pressure me to eat.| <*Answer_8439*>| |\n 21. Give too much time and thought to food.| <*Answer_8440*>| |\n 22. Feel uncomfortable after eating sweets.| <*Answer_8441*>| |\n 23. Engage in dieting behavior.| <*Answer_8442*>| |\n 24. Like my stomach to be empty.| <*Answer_8443*>| |\n 25. Have the impulse to vomit after meals.| <*Answer_8444*>| |\n 26. Enjoy trying new rich foods.| <*Answer_8445*>| |\n \n \nPart C:||\n| Gender: <.Patient_Gender.>| |\n \n A. Gone on eating binges where you feel that you may not be able to stop?| <*Answer_8446*>| |\n B. Ever made yourself sick (vomited) to control your weight or shape?| <*Answer_8447*>| |\n C. Ever used laxatives, diet pills or diuretics (water pills) to control|\n your weight or shape?| <*Answer_8448*>| |\n D. Exercised more than 60 minutes a day to lose or to control your weight?| <*Answer_8449*>| |\n E. Lost 20 pounds or more in the past 6 months?| <*Answer_8450*>\n| \n|\n|(c) The EAT-26 has been reproduced with permission. Garner et al. (1982).\n \n| \n|Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes.\n Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities.\nEAT-26 Total Score = <-TOTAL SCORE-> | |\n \nBMI = <*Answer_7772*>| |\n
\n\n"], ["182", "ACE\n", "\n|.||Adverse Childhood Experiences (ACE)|\nprevalence of physical and mental health risks.| |\n \n \nQuestions and Answers:|\n 1. Did a parent or other adult in the household often or very often...Swear|\n at you, insult you, put you down, or humiliate you? or Act in a way that|\n made you afraid that you might be physically hurt?| <*Answer_8460*>| |\n 2. Did a parent or other adult in the household often or very often...Push,|\n grab, slap, or throw something at you? or Ever hit you so hard that you|\n had marks or were injured?| <*Answer_8461*>| |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n 3. Did an adult person at least 5 years older than you ever...Touch or |\n fondle you or have you touch their body in a sexual way? or Attempt|\n or actually have oral, anal, or vaginal intercourse with you?| <*Answer_8462*>| |\n 4. Did you often or very often feel that...No one in your family loved|\n you or thought you were important or special? or Your family didn't|\n look out for each other, feel close to each other, or support each|\n other?| <*Answer_8463*>| |\n 5. Did you often or very often feel that...You didn't have enough to |\n eat, had to wear dirty clothes, and had no one to protect you? or|\n Your parents were too drunk or high to take care of you or take |\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n you to the doctor if you needed it?| <*Answer_8464*>| |\n 6. Were your parents ever separated or divorced?| <*Answer_8465*>| |\n 7. Was your mother or stepmother: Often or very often pushed, grabbed,|\n slapped, or had something thrown at her? or Sometimes, often, or |\n very often kicked, bitten, hit with a fist, or hit with something|\n hard? or Ever repeatedly hit at least a few minutes or threatened|\n with a gun or knife?| <*Answer_8466*>| |\n 8. Did you live with anyone who was a problem drinker or alcoholic or|\n who used street drugs?| <*Answer_8467*>| |\n 9. Was a household member depressed or mentally ill, or did a house-|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n hold member attempt suicide?| <*Answer_8467*>| |\n10. Did a household member go to prison?| <*Answer_8469*>| |\n \nInformation contained in this note is based on a self-report assessment |\n and is not sufficient to use alone for diagnostic purposes. Assessment |\n results should be verified for accuracy and used in conjunction with |\n other diagnostic activities.| |\n$~\n| Gender: <.Patient_Gender.>| |\n \nACE Total Score = <-Total Score->| | \n \nTotal scores range from 0 - 10. The higher the score, the higher the| \n
\n\n"], ["183", "CMQ\n", "\n|.|.|Composite Morningness Questionnaire (CMQ) |\n a morning type, and scores in between receive a classification of|\n intermediate.| |\n \nQuestions and Answers:| |\n \n1. Considering only your own "feeling best" rhythm, at what time would you get|\n up if you were entirely free to plan your day?|\n <*Answer_8470*>||\n 2. Considering your only "feeling best" rhythm, at what time would you go to|\n bed if you were entirely free to plan your evening?|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n <*Answer_8471*>||\n 3. Assuming normal circumstance, how easy do you find getting up in the |\n morning?|\n <*Answer_8472*>||\n 4. How alert do you feel during the first half hour after having awakened|\n in the morning?|\n <*Answer_8473*>||\n 5. During the first half hour after having awakened in the morning, how |\n tired to you feel?|\n <*Answer_8474*>||\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n 6. You have decided to engage in some physical exercise. A friend suggests|\n that you do this one hour twice a week and the best time for him is |\n 7:00-8:00 a.m. Bearing in mind nothing else but your own "feeling best"|\n rhythm, how do you think you would perform?|\n <*Answer_8475*>||\n 7. At what time in the evening do you feel tired and, as a result, in |\n need of sleep?|\n <*Answer_8476*>||\n 8. You wish to be at your peak performance for a test which you know is |\n going to be mentally exhausting and lasting for two hours. You are|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n entirely free to plan your day, and considering only your own "feeling|\n best" rhythm, which ONE of the four testing times would you choose?|\n <*Answer_8477*>||\n 9. One hears about "morning" and "evening" types of people. Which ONE |\n of these types do you consider yourself to be?|\n <*Answer_8478*>||\n10. When would you prefer to rise (provided you have a full day's work- |\n 8 hours) if you were totally free to arrange your time?|\n <*Answer_8479*>||\n11. If you always had to rise at 6:00 a.m., what do you think it would |\n| Gender: <.Patient_Gender.>| |\n be like?|\n <*Answer_8480*>||\n12. How long a time does it usually take before you "recover your senses"|\n in the morning after rising from a night's sleep?|\n <*Answer_8481*>||\n13. Please indicate to what extend you are a morning or evening active |\n individual.|\n <*Answer_8482*>\n| | \nInformation contained in this note is based on a self-report assessment|\n \n and is not sufficient to use alone for diagnostic purposes. Assessment|\n results should be verified for accuracy and used in conjunction with |\n other diagnostic activities.||\n \nCopyright [1989] by the American Psychological Association. Reproduced |\n with permission. The official citation that should be used in referencing|\n this material is [Smith CS, Reilly C, Midkiff K. Evaluation of three |\n circadian rhythm questionnaires with suggestions for an improved measure|\n of morningness. J Appl Psychol. Oct 1989;74(5):728-738]. The use of APA|\n information does not imply endorsement by APA.\nCMQ Total Score = <-CMQ Total Score->| |\n$~\n \nA score of 22 or below indicates an evening type, a score above 44 indicates |\n
\n\n"], ["184", "SIP-AD-30\n", "\n|.|.|SHORT INVENTORY OF PROBLEMS - AD (SIP-AD-30) |\n \nSubscale Scores:||\n \nPhysical = <-Physical->|\n Interpersonal = <-Interpersonal->|\n Intrapersonal = <-Intrapersonal->|\n Impulse control = <-Impulse control->|\n Social Responsibility = <-Social Responsibility->||\n \nPast 30-day total scores range from 0-45. Higher scores indicate more |\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n negative consequences associated with drinking or drug use within the |\n past 30 days. Subscale scores range from 0-9.| |\n \n \nQuestions and Answers||\n \n 1. I have been unhappy because of my drinking or drug use.|\n <*Answer_8483*>| |\n \n 2. Because of my drinking or drug use I have not eaten.|\nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n <*Answer_8484*>| |\n \n 3. I have failed to do what was expected of me because of my drinking or |\n drug use.|\n <*Answer_8485*>| |\n \n 4. I have felt guilty or ashamed because of my drinking or drug use.|\n <*Answer_8486*>| |\n \n 5. I have taken foolish risks when I have been drinking or using drugs.|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n <*Answer_8487*>| |\n \n 6. When drinking or using drugs, I have done impulsive things that I|\n regretted later.|\n <*Answer_8488*>| |\n \n 7. I have been harmed by my drinking or drug use.|\n <*Answer_8489*>| |\n \n 8. I have had money problems because of my drinking or drug use.|\n| Gender: <.Patient_Gender.>| |\n <*Answer_8490*>| |\n \n 9. My physical appearance has been harmed by my drinking or drug use.|\n <*Answer_8491*>| |\n \n10. My family has been hurt by my drinking or drug use.|\n <*Answer_8492*>| |\n \n11. A friendship or close relationship has been damaged by my drinking or |\n drug use.|\n \n <*Answer_8493*>| |\n \n12. My drinking or drug use has gotten in the way of my growth as a person.|\n <*Answer_8494*>| |\n \n13. My drinking or drug use has damaged my social life, popularity, and |\n reputation.|\n <*Answer_8495*>| |\n \n14. I have spent too much or lost a lot of money because of my drinking or |\nSession number: <*Answer_8529*>| |\n drug use.|\n <*Answer_8496*>| |\n \n15. I have had an accident while using or under the influence of alcohol or |\n drugs.|\n <*Answer_8497*>||\n \nInformation contained in this note is based on a self-report assessment and |\n is not sufficient to use alone for diagnostic purposes. Assessment results |\n should be verified for accuracy and used in conjunction with other diagnostic |\n \n activities.| |\n \n$~\nSIP-AD PAST 30-DAY TOTAL SCORE = <-PAST 30 DAY TOTAL SCORE->||\n
\n\n"], ["185", "SIP-AD-START\n", "\n|.|.|SHORT INVENTORY OF PROBLEMS - AD (SIP-AD-START) |\n \nLifetime Total scores range from 0-15. Higher scores indicate more negative|\n consequences associated with drinking or drug use across the lifetime.||\n \nSIP-AD PAST 30-DAY TOTAL SCORE = <-30-DAY TOTAL SCORE->||\n \nSubscale Scores:||\n \nPhysical = <-Physical->|\n Interpersonal = <-Interpersonal->|\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| \n Intrapersonal = <-Intrapersonal->|\n Impulse control = <-Impulse control->|\n Social Responsibility = <-Social Responsibility->||\n \nPast 30-day total scores range from 0-45. Higher scores indicate more negative|\n consequences associated with drinking or drug use within the past 30 days.|\n Subscale scores range from 0-9.||\n \nQuestions and Answers||\n \nLocation: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nI have been unhappy because of my drinking or drug use.|\n 1a. Ever: <*Answer_8498*>|\n 1b. In the past 30 days: <*Answer_8499*>| |\n \nBecause of my drinking or drug use I have not eaten.|\n 2a. Ever: <*Answer_8500*>|\n 2b. In the past 30 days: <*Answer_8501*>| |\n \nI have failed to do what was expected of me because of my drinking or drug use.|\n 3a. Ever: <*Answer_8502*>|\nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n 3b. In the past 30 days: <*Answer_8503*>| |\n \nI have felt guilty or ashamed because of my drinking or drug use.|\n 4a. Ever: <*Answer_8504*>|\n 4b. In the past 30 days: <*Answer_8505*>| |\n \nI have taken foolish risks when I have been drinking or using drugs.|\n 5a. Ever: <*Answer_8506*>|\n 5b. In the past 30 days: <*Answer_8507*>| |\n \n| Gender: <.Patient_Gender.>| |\nWhen drinking or using drugs, I have done impulsive things that I regretted |\n later.|\n 6a. Ever: <*Answer_8508*>|\n 6b. In the past 30 days: <*Answer_8509*>| |\n \nI have been harmed by my drinking or drug use.|\n 7a. Ever: <*Answer_8510*>|\n 7b. In the past 30 days: <*Answer_8511*>| |\n \nI have had money problems because of my drinking or drug use.|\n \n 8a. Ever: <*Answer_8512*>|\n 8b. In the past 30 days: <*Answer_8513*>| |\n \nMy physical appearance has been harmed by my drinking or drug use.|\n 9a. Ever: <*Answer_8514*>|\n 9b. In the past 30 days: <*Answer_8515*>| |\n \nMy family has been hurt by my drinking or drug use.|\n 10a. Ever: <*Answer_8516*>|\n 10b. In the past 30 days: <*Answer_8517*>| |\nSession number: <*Answer_8528*> | |\n \nA friendship or close relationship has been damaged by my drinking or drug use.|\n 11a. Ever: <*Answer_8518*>|\n 11b. In the past 30 days: <*Answer_8519*>| |\n \nMy drinking or drug use has gotten in the way of my growth as a person.|\n 12a. Ever: <*Answer_8520*>|\n 12b. In the past 30 days: <*Answer_8521*>||\n \nMy drinking or drug use has damaged my social life, popularity, and |\n \n reputation.|\n 13a. Ever: <*Answer_8522*>|\n 13b. In the past 30 days: <*Answer_8523*>| |\n \nI have spent too much or lost a lot of money because of my drinking or |\n drug use.|\n 14a. Ever: <*Answer_8524*>|\n 14b. In the past 30 days: <*Answer_8525*>| |\n \nI have had an accident while using or under the influence of alcohol or |\nSIP-AD-LIFETIME TOTAL SCORE = <-LIFETIME SCORE->||\n drugs.|\n 15a. Ever: <*Answer_8526*>|\n 15b. In the past 30 days: <*Answer_8527*>| |\n \nInformation contained in this note is based on a self-report assessment and|\n is not sufficient to use alone for diagnostic purposes. Assessment results|\n should be verified for accuracy and used in conjunction with other diagnostic|\n activities.| |\n$~\n
\n\n"], ["186", "NUDESC\n", "\n|.|.|Nursing Delirium Screening Scale - (NUDESC) |\n \nMaximum total score is 10. Scores greater than/equal to 2 are considered|\n postive.||\n \nQuestions and Answers| |\n \n1. DISORIENTATION. Verbal or behavioral manifestation of not being \noriented|\n to time or place or misperceiving persons in the environment.|\n <*Answer_7772*>||\n | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|\n 2. INAPPROPRIATE BEHAVIOR. Behavior inappropriate to place and/or for the|\n person; e.g., pulling at tubes or dressings, attempting to get out of bed|\n when it is contraindicated, and the like.|\n <*Answer_7773*>||\n 3. INAPPROPRIATE COMMUNICATION. Behavior inappropriate to place and/or for the|\n person; e.g., incoherence, non-communicativeness, nonsensical or|\n unintelligible speech.|\n <*Answer_7774*>||\n 4. ILLUSIONS/HALLUCINATIONS. Seeing or hearing things that are not there;|\n distortions of visual objects.|\n Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|\n <*Answer_7775*>||\n 5. PSYCHOMOTOR RETARDATION. Delayed responsiveness; few or no spontaneous |\n actions/words; e.g., when the patient is prodded, reaction is deferred |\n and/or the patient is unarousable.|\n <*Answer_7776*>| |\n \nInformation contained in this note is based on a self-report assessment and|\n is not sufficient to use alone for diagnostic purposes. Assessment results |\n should be verified for accuracy and used in conjunction with other diagnostic|\n activities.||\n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n$~\n| Gender: <.Patient_Gender.>| |\n \nNuDESC score indicates a <*Answer_7771*> screen for delirium.| |\n \nTotal Score = <-TOTAL SCORE->| |\n
\n\n"], ["187", "CASE MIX\n", "\n| HCBS Case Mix & Budget Tool (CASE MIX)|\n| Q15. SPECIAL NURSING\n| <*Answer_8550*>\n| Q16. NEUROMUSCULAR DIAGNOSIS"\n| <*Answer_8551*>\n| COMMENTS\n| <*Answer_8552*>\n| SOURCES\n| <*Answer_8553*>\n| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>\n| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>| \n| Type of Evaluation: <*Answer_8580*>\n| Anticipated Start Date: <*Answer_8581*>\n| Anticipated Length of Service: <*Answer_8582*>|\n| <*Answer_7771*>\n| Questions and Answers:|<*Answer_7772*>\n
\n\n"], ["188", "PHI\n", "\n|Personal Health Inventory (PHI)|\n| What is your mission, aspiration, or purpose? What do you live for? What \n| matters most to you?\n| <*Answer_7773*>\n|\n| \n| Self Care: This is where I am now and where I want to be in the following\n| areas of self care.\n|\n| Area of Self Care Where I am Now Where I Want to Be\n| ----------------- -------------- ------------------\n| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>\n<*Answer_7772*>\n|\n| \n| Reflections\n| -----------\n| \n| Now that you have thought about what matters to you in all of these areas, \n| what is your vision of your best possible self? What would your life look \n| like? What kind of activities would you be doing?\n| <*Answer_7774*>\n| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n|\n| Are there any areas you would like to work on? Where might you start?\n| <*Answer_7775*>\n| Gender: <.Patient_Gender.>|\n| Questions and Answers\n| =====================\n|\n<*Answer_7771*> \n| \n
\n\n"], ["189", "PROMIS29+2 V2.1\n", "\n|Patient Reported Outcome Measurement Information System (PROMIS) 29+2 Profile\n| Gender: <.Patient_Gender.>\n| |<*Answer_7771*>\n| | \n|Questions and Answers| \n|Physical Function:\n| 1. Are you able to do chores such as vacuuming or yard work?\n| <*Answer_8583*>\n| 2. Are you able to go up and down stairs at a normal pace?\n| <*Answer_8584*>\n| 3. Are you able to go for a walk of at least 15 minutes?\n|PROMIS29+2 Profile v2.1 (PROPr)\n| <*Answer_8585*>\n| 4. Are you able to run errands and shop?\n| <*Answer_8586*>|\n|Anxiety: In the past 7 days...\n| 5. I felt fearful.\n| <*Answer_8587*>\n| 6. I found it hard to focus on anything other than my anxiety.\n| <*Answer_8588*>\n| 7. My worries overwhelmed me.\n| <*Answer_8589*>\n| \n| 8. I felt uneasy.\n| <*Answer_8590*>|\n|Depression: In the past 7 days...\n| 9. I felt worthless.\n| <*Answer_8591*>\n|10. I felt helpless.\n| <*Answer_8592*>\n|11. I felt depressed.\n| <*Answer_8593*>\n|12. I felt hopeless.\n| Date Given: <.Date_Given.>\n| <*Answer_8594*>|\n|Fatigue: During the past 7 days...\n|13. I feel fatigued.\n| <*Answer_8595*>\n|14. I have trouble STARTING things because I am tired. \n| <*Answer_8596*>\n|15. How run down did you feel on average?\n| <*Answer_8597*>\n|16. How fatigued were you on average?\n| <*Answer_8598*>|\n| Clinician: <.Staff_Ordered_By.>\n|Sleep Disturbance: In the past 7 days...\n|17. My sleep quality was\n| <*Answer_8599*>\n|18. My sleep was refreshing.\n| <*Answer_8600*>\n|19. I had a problem with my sleep.\n| <*Answer_8601*>\n|20. I had difficulty falling asleep.\n| <*Answer_8602*>|\n|Ability to Participate in Social Roles and Activities:\n| Location: <.Location.>| \n|21. I have trouble doing all of my regular leisure activities with others.\n| <*Answer_8603*>\n|22. I have trouble doing all of the family activities that I want to do.\n| <*Answer_8604*>\n|23. I have trouble doing all of my usual work (include work at home).\n| <*Answer_8605*>\n|24. I have trouble doing all of the activities with friends that I want to do.\n| <*Answer_8606*>|\n|Pain Interference: In the past 7 days...\n|25. How much did pain interfere with your day to day activities?\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_8607*>\n|26. How much did pain interfere with work around the home?\n| <*Answer_8608*>\n|27. How much did pain interfere with your ability to participate in social\n| activities?\n| <*Answer_8609*>\n|28. How much did pain interfere with your household chores?\n| <*Answer_8610*>|\n|Cognitive Function -- Abilities: In the past 7 days...\n|29. I have been able to concentrate.\n| SSN: <.Patient_SSN.>\n| <*Answer_8611*>\n|30. I have been able to remember to do things, like take medicine or buy\n| something I needed.\n| <*Answer_8612*>|\n|Pain Intensity: In the past 7 days...\n|31. How would you rate your pain on average?\n| <*Answer_8613*>\n| \n| \n|Information contained in this note is based on a self-report assessment \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| \n| 2008-2016 PROMIS Health Organization and PROMIS Cooperative Group\n
\n\n"], ["19", "PAS-EQUIP\n", "\n|Enhancing Quality of Care in Psychosis||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nyour doctor for mental health problems?| <*Answer_4429*>|26.Do you know the names of your medications that you are prescribed?| <*Answer_4430*>|27.Here is a list of medications you may be \nprescribed. Check all of the medications that you are currently prescribed.| <*Answer_4431*>|28.Over the past month, to what extent have you taken the medications prescribed by your doctor for \nmental health problems?| <*Answer_4432*>|29.What is your height: How many feet?| <*Answer_4433*>|How many inches:| <*Answer_4434*>|30.What is your weight in pounds?| \n<*Answer_4435*>|31.Have you been weighing yourself every week at home?| <*Answer_4436*>|32.Over the past month, have you gained or lost weight or stayed the same?| <*Answer_4437*>|33.How \nmuch weight have you gained?| <*Answer_4438*>|34.How much weight have you lost?| <*Answer_4439*>|35.Has your doctor recently talked with you about changing to medication that does not cause \nweight gain?| <*Answer_4440*>|36.Has your doctor recently recommended that you go to wellness or weight loss groups?| <*Answer_4441*>|37.How many times in the past month did you attend \nwellness or weight loss groups?| <*Answer_4442*>|39.Have you changed your diet in order to lose weight?| <*Answer_4443*>|40.Have you increased your physical activity recently in order to lose \nweight?| <*Answer_4444*>|41.Have you ever had angina, a heart attack, or a stroke?| <*Answer_4445*>|42.Do you currently have diabetes or hypertension, or are you being treated for diabetes or \nhypertension?| <*Answer_4455*>|43.Are you currently working in a job for pay?| <*Answer_4446*>|44.How many weeks have you worked at this job?| <*Answer_4447*>|45.How many hours a week do \nyou usually work?| <*Answer_4448*>|46.Is this a job that anyone can apply for, or is it only for disabled people?| <*Answer_4449*>|47.How many dollars did you earn last month?| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1.Managing your day-to-day life?| <*Answer_4405*>|2.Coping with problems in your life?| \n<*Answer_4450*>|48.Is this the total gross income from the job, or the amount of take-home pay from the job?| <*Answer_4456*>|49.Would you be interested in working at a paying job if it would \nnot affect your benefits too much and you could get the support you need?| <*Answer_4451*>|50.Has your doctor recently recommended that you go to the VA's work program---called "IPS" or \n"supported employment" ?| <*Answer_4452*>|51.How many times in the past month did you attend the VA's work program called IPS or supported employment?| <*Answer_4453*>|52.During the past \nmonth, how many job interviews have you gone to?| <*Answer_4454*>| $~\n<*Answer_4406*>|3.Concentrating?| <*Answer_4407*>|4.Get along with people in your family?| <*Answer_4408*>|5.Get along with people outside your family?| <*Answer_4409*>|6.Get along well \nin social situations?| <*Answer_4410*>|7.Feel close to another person?| <*Answer_4411*>|8.Feel like you had someone to turn to if you needed help?| <*Answer_4412*>|9.Feel confident in \nyourself?| <*Answer_4413*>|10.Feel sad or depressed?| <*Answer_4414*>|11.Think about ending your life?| <*Answer_4415*>|12.Feel nervous?| <*Answer_4416*>|13.Have thoughts racing \nthrough your head?| <*Answer_4417*>|14.Think you had special powers?| <*Answer_4418*>|15.Hear voices or see things?| <*Answer_4419*>|16.Think people were watching you?| \n<*Answer_4420*>|17.Think people were against you?| <*Answer_4421*>|18.Have mood swings?| <*Answer_4422*>|19.Feel short-tempered?| <*Answer_4423*>|20.Think about hurting yourself?| \n<*Answer_4424*>|21.Did you have an urge to drink alcohol or take street drugs?| <*Answer_4425*>|22.Did anyone talk to you about your drinking or drug use?| <*Answer_4426*>|23.Did you try to \nhide your drinking or drug use?| <*Answer_4427*>|24.Did you have problems from your drinking or drug use?| <*Answer_4428*>|25.Over the past month have you been prescribed any medication by \n
\n\n"], ["190", "PROMIS29 V2.1\n", "\n|Patient Reported Outcome Measurement Information System (PROMIS) 29 Profile\n| Gender: <.Patient_Gender.>\n| |<*Answer_7771*>\n| | \n|Questions and Answers| \n|Physical Function:\n| 1. Are you able to do chores such as vacuuming or yard work?\n| <*Answer_8583*>\n| 2. Are you able to go up and down stairs at a normal pace?\n| <*Answer_8584*>\n| 3. Are you able to go for a walk of at least 15 minutes?\n|PROMIS29 Profile v2.1\n| <*Answer_8585*>\n| 4. Are you able to run errands and shop?\n| <*Answer_8586*>|\n|Anxiety: In the past 7 days...\n| 5. I felt fearful.\n| <*Answer_8587*>\n| 6. I found it hard to focus on anything other than my anxiety.\n| <*Answer_8588*>\n| 7. My worries overwhelmed me.\n| <*Answer_8589*>\n| \n| 8. I felt uneasy.\n| <*Answer_8590*>|\n|Depression: In the past 7 days...\n| 9. I felt worthless.\n| <*Answer_8591*>\n|10. I felt helpless.\n| <*Answer_8592*>\n|11. I felt depressed.\n| <*Answer_8593*>\n|12. I felt hopeless.\n| Date Given: <.Date_Given.>\n| <*Answer_8594*>|\n|Fatigue: During the past 7 days...\n|13. I feel fatigued.\n| <*Answer_8595*>\n|14. I have trouble STARTING things because I am tired. \n| <*Answer_8596*>\n|15. How run down did you feel on average?\n| <*Answer_8597*>\n|16. How fatigued were you on average?\n| <*Answer_8598*>|\n| Clinician: <.Staff_Ordered_By.>\n|Sleep Disturbance: In the past 7 days...\n|17. My sleep quality was\n| <*Answer_8599*>\n|18. My sleep was refreshing.\n| <*Answer_8600*>\n|19. I had a problem with my sleep.\n| <*Answer_8601*>\n|20. I had difficulty falling asleep.\n| <*Answer_8602*>|\n|Ability to Participate in Social Roles and Activities:\n| Location: <.Location.>| \n|21. I have trouble doing all of my regular leisure activities with others.\n| <*Answer_8603*>\n|22. I have trouble doing all of the family activities that I want to do.\n| <*Answer_8604*>\n|23. I have trouble doing all of my usual work (include work at home).\n| <*Answer_8605*>\n|24. I have trouble doing all of the activities with friends that I want to do.\n| <*Answer_8606*>|\n|Pain Interference: In the past 7 days...\n|25. How much did pain interfere with your day to day activities?\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_8607*>\n|26. How much did pain interfere with work around the home?\n| <*Answer_8608*>\n|27. How much did pain interfere with your ability to participate in social\n| activities?\n| <*Answer_8609*>\n|28. How much did pain interfere with your household chores?\n| <*Answer_8610*>|\n|Pain Intensity: In the past 7 days...\n|29. How would you rate your pain on average?\n| SSN: <.Patient_SSN.>\n| <*Answer_8613*>\n| \n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| \n| 2008-2016 PROMIS Health Organization and PROMIS Cooperative Group\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["191", "SRCS\n", "\n|Suicide-Related Coping Scale (SRCS)\n| Gender: <.Patient_Gender.>\n| \n| SRCS Total Score = <-SRCS Total->\n| Internal Coping = <-Internal Coping->\n| External Coping = <-External Coping->\n| \n| \n|Questions and Answers:\n| \n| 1. I have contact information for at least one health care professional\n| \n| (such as doctor or therapist) whom I can call during a suicidal \n| crisis.\n| <*Answer_8614*>\n| 2. I cannot do anything to control my suicidal thoughts.\n| <*Answer_8615*>\n| 3. I know which friends and/or family members to contact to help take\n| my mind off my suicidal feelings.\n| <*Answer_8616*>\n| 4. I know the nearest hospital or urgent care facility where I can go\n| if I cannot handle my suicidal feelings.\n| Date Given: <.Date_Given.>\n| <*Answer_8617*>\n| 5. When I feel suicidal, there are places I can go (such as a coffee\n| shop, the gym, place of worship, or shopping mall) to help me take\n| my mind off my problems.\n| <*Answer_8618*>\n| 6. I have several things I can do to get through a suicidal crisis.\n| <*Answer_8619*>\n| 7. I am able to confide in someone, such as a friend, family member,\n| supervisor, or spiritual advisor when I am experiencing a crisis.\n| <*Answer_8620*>\n| Clinician: <.Staff_Ordered_By.>\n| 8. Seeking help from health care professionals is a good way to keep\n| myself safe when I am feeling suicidal.\n| <*Answer_8621*>\n| 9. I know it is important to limit access to weapons or other ways to\n| hurt myself when I am feeling suicidal.\n| <*Answer_8622*>\n| 10. Even if I am alone, there are things I can do to take mind off my\n| suicidal feelings and thoughts for at least a while.\n| <*Answer_8623*>\n| 11. I do not think there is anything that I can do to help myself when\n| Location: <.Location.>\n| I am feeling suicidal.\n| <*Answer_8624*>\n| 12. It is useless to talk to anyone about my suicidal thoughts.\n| <*Answer_8625*>\n| 13. When I am suicidal, I know of things to do by myself that help me\n| feel less suicidal.\n| <*Answer_8626*>\n| 14. I can distract myself by doing other things or thinking about other\n| things when I am feeling suicidal.\n| <*Answer_8627*>\n| \n| 15. If one way of trying to cope with suicidal feelings does not work,\n| I have other ways to try.\n| <*Answer_8628*>\n| 16. I am at the mercy of my suicidal thoughts.\n| <*Answer_8629*>\n| 17. I feel that I have no one to turn to when I am feeling suicidal.\n| <*Answer_8630*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| Veteran: <.Patient_Name_Last_First.>\n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["192", "NPO-Q\n", "\n|Negative Problem Orientation Questionnaire (NPO-Q)\n| Gender: <.Patient_Gender.>\n| \n| Score = <-NPO-Q Total->\n| Higher total scores indicate a more negative problem orientation. \n| \n|Questions and Answers:\n| \n| 1. I see problems as a threat to my well-being.\n| <*Answer_8631*>\n| 2. I often doubt my capacity to solve problems.\n| \n| <*Answer_8632*>\n| 3. Often before even trying to find a solution, I tell myself that it \n| is difficult to solve problems.\n| <*Answer_8633*>\n| 4. My problems often seem insurmountable.\n| <*Answer_8634*>\n| 5. When I attempt to solve a problem, I often question my abilities.\n| <*Answer_8635*>\n| 6. I often have the impression that my problems cannot be solved.\n| <*Answer_8636*>\n| Date Given: <.Date_Given.>\n| 7. Even if I manage to find some solutions to my problems, I doubt that \n| they will be easily resolved.\n| <*Answer_8637*>\n| 8. I have a tendency to see problems as a danger.\n| <*Answer_8638*>\n| 9. My first reaction when faced with a problem is to question my \n| abilities.\n| <*Answer_8639*>\n| 10. I often see my problems as bigger than they really are.\n| <*Answer_8640*>\n| Clinician: <.Staff_Ordered_By.>\n| 11. Even if I have looked at a problem from all possible angles, I still \n| wonder if the solution I decided on will be effective.\n| <*Answer_8641*>\n| 12. I consider problems to be obstacles that interfere with my \n| functioning.\n| <*Answer_8642*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n| Location: <.Location.>\n|other diagnostic activities.\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["193", "B-IPF\n", "\n|Brief Inventory of Psychosocial Functioning (B-IPF)\n| Gender: <.Patient_Gender.>\n| \n| B-IPF Total Score = <-B-IPF Total-> (<*Answer_7772*>)\n| \n| \n|Questions and Answers:\n| \n| 1. I had trouble in my romantic relationship with my spouse or partner.\n| <*Answer_8643*>\n| 2. I had trouble in my relationship with my children.\n| \n| <*Answer_8644*>\n| 3. I had trouble with my family relationships.\n| <*Answer_8645*>\n| 4. I had trouble with my friendships and socializing.\n| <*Answer_8646*>\n| 5. I had trouble at work.\n| <*Answer_8647*>\n| 6. I had trouble with my training and education.\n| <*Answer_8648*>\n| 7. I had trouble with day to day activities, such as doing household\n| Date Given: <.Date_Given.>\n| chores, running errands and managing my medical care.\n| <*Answer_8649*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["194", "CAT-CAD Interview\n", "\n|Computerized Adaptive Interview\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n|<*Answer_7772*>\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n
\n\n"], ["195", "CAT-DEP\n", "\n|Depression, Computerized Adaptive Test (CAT-DEP)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["196", "CAT-ANX\n", "\n|Anxiety Disorder, Computerized Adaptive Test (CAT-ANX)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["197", "CAT-MANIA-HYPOMANIA\n", "\n|Mania/Hypomania, Computerized Adaptive Test (CAT-MANIA-HYPOMANIA)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["198", "CAT-SUD\n", "\n|Substance Use Disorder, Computerized Adaptive Test (CAT-SUD)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["199", "CAT-PTSD\n", "\n|Post-Traumatic Stress Disorder, Computerized Adaptive Test (CAT-PTSD)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["2", "FAST\n", "\n|Functional Assessment Staging\n|Gender: <.Patient_Gender.>\n|\n|FAST Stage: <-Stage->\n|\n| Stage 1: Normal adult\n| Stage 2: Normal older adult\n| Stage 3: Early dementia\n| Stage 4: Mild dementia\n| Stage 5: Moderate dementia\n| Stage 6: Moderately severe dementia\n|\n| Stage 7: Severe dementia\n|\n|Questions and Answers\n|\n|<*Answer_7771*>\n|<*Answer_7772*>\n|<*Answer_7773*>\n|<*Answer_7774*>\n|<*Answer_7775*>\n|<*Answer_7776*>\n|Date Given: <.Date_Given.>\n|<*Answer_7777*>\n|<*Answer_7778*>\n|<*Answer_7779*>\n|<*Answer_7780*>\n|<*Answer_7781*>\n|<*Answer_7782*>\n|<*Answer_7783*>\n|<*Answer_7784*>\n|<*Answer_7785*>\n|<*Answer_7786*>\n|Clinician: <.Staff_Ordered_By.>\n|\n|Copyright (c) 1984 by Barry Reisberg, M.D., Reproduced with permission.\n|\n|Information contained in this note is based on a self-report assessment and is not sufficient to use alone for\n diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other\n diagnostic activities and procedures.\n|Location: <.Location.>\n|\n|Veteran: <.Patient_Name_Last_First.>\n|SSN: <.Patient_SSN.>\n|DOB:<.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["20", "PAS-EQUIP\n", ""], ["200", "CAT-PSY-C\n", "\n|Psychosis - Clinician, Computerized Adaptive Test (CAT-PSY-C)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["201", "CAT-PSY-S\n", "\n|Psychosis - Self-Report, Computerized Adaptive Test (CAT-PSY-S)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["202", "CAT-ADHD\n", "\n|Adult ADHD, Computerized Adaptive Test (CAT-ADHD)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["203", "CAT-SDOH\n", "\n|Social Determinants of Health, Computerized Adaptive Test (CAT-SDOH)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["204", "CAT-SS\n", "\n|Suicide Scale, Computerized Adaptive Test (CAT-SS)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["205", "CAD-MDD\n", "\n|Major Depressive Disorder, Computerized Adaptive Diagnosis (CAD-MDD)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["206", "CAD-PTSD-DX\n", "\n|PTSD-Diagnosis, Computerized Adaptive Diagnosis (CAD-PTSD)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["207", "CAT-PTSD-E\n", "\n|PTSD-Expanded, Computerized Adaptive Diagnosis (CAT-PTSD-E)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["208", "CAT-PSYCHOSIS\n", "\n|Psychosis - Computerized Adaptive Test (CAT-PSY)\n| Gender: <.Patient_Gender.>\n<*Answer_7771*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2020 Adaptive Testing Technologies, Inc. All Rights Reserved\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["209", "EHS-14\n", "\n|Short Employment Hope Scale (EHS-14)\n| Gender: <.Patient_Gender.>\n|<*Answer_7771*>\n| \n| The range for total score and each subscale is 0-10.\n| Higher scores indicate higher levels of Employment Hope.\n| \n| If the Veteran completed the Perceived Employment Barriers Scale (PEBS-20\n| or PEBS-27) today, you can use that to calculate the Psychological Self-\n| Sufficiency score by subtracting the PEBS total score from the EHS total \n| score.\n| \n|\n|\n|Questions and Answers:\n|\n| PSYCHOLOGICAL EMPOWERMENT \n| 1. When working or looking for a job, I am respectful towards who I am.\n| <*Answer_8651*>\n| 2. I am worthy of working in a good job.\n| <*Answer_8652*>\n| 3. I am capable of working in a good job.\n| Date Given: <.Date_Given.>\n| <*Answer_8653*>\n| 4. I have the strength to overcome any obstacles when it comes to \n| working.\n| <*Answer_8654*>\n|\n| FUTURISTIC SELF-MOTIVATION\n| 5. I am going to be working in a career job.\n| <*Answer_8655*>\n| 6. I feel energized when I think about future achievement with my job.\n| <*Answer_8656*>\n| Clinician: <.Staff_Ordered_By.>\n| \n| UTILIZATION OF SKILLS AND RESOURCES\n| 7. I am aware of what my skills are to be employed in a good job.\n| <*Answer_8657*>\n| 8. I am aware of what my resources are to be employed in a good job.\n| <*Answer_8658*>\n| 9. I am able to utilize my skills to move toward career goals.\n| <*Answer_8659*>\n| 10. I am able to utilize my resources to move toward career goals.\n| <*Answer_8660*>\n| Location: <.Location.>\n|\n| GOAL ORIENTATION\n| 11. I am on the road toward my career goals.\n| <*Answer_8661*>\n| 12. I am in the process of moving forward toward reaching my goals.\n| <*Answer_8662*>\n| 13. Even if I am not able to achieve my financial goals right away, I \n| will find a way to get there.\n| <*Answer_8663*>\n| 14. My current path will take me to where I need to be in my career.\n| \n| <*Answer_8664*>\n|\n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2016 Loyola University Chicago All Rights Reserved\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["21", "Hendrich II\n", "\n| Hendrich II Fall Risk Model| | Date Given: <.Date Given.>| Clinician: <.Staff: Ordered By.>| Location: <.Location.>| | Veteran:\n <.Patient Name: Last, First.>| SSN: <.Patient: SSN.>| DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>)| Gender\n: <.Patient: Gender.>| | | Confusion/Disorientation/Impulsivity| <*Answer_5453*>\n| Depression| <*Answer_5454*>| Altered elimination| <*Answer_5455*>| Dizziness/vertigo| <*Answer_5456*>| Gender\n| <*Answer_5457*>| Any prescribed antiepileptics| <*Answer_5458*>| Any prescribed benzodiazepines| <*Answer_5459*>\n| Get-up- go Test Item #2: "Rising from chair"| <*Answer_5460*>\n| | ------------------------------------------------------------------| A score of 5 or greater indicates high risk.| | Hendrich II Fall Risk Score: <-Fall Risk Score->| | | | | $~\n
\n\n"], ["210", "PEBS-27\n", "\n|Perceived Employment Barriers Scale (PEBS-27)\n| Gender: <.Patient_Gender.>\n|<*Answer_7771*> \n| \n| The range for the total score and each subscale is 1-5. \n| Higher scores indicate higher perception of Employment Barriers.\n| \n| If the Veteran completed the Employment Hope Scale (EHS-14) today, you\n| can use that to calculate the Psychological Self-Sufficiency Score by \n| subtracting the PEBS total score from the EHS total score.\n| \n| \n| \n|Questions and Answers:\n| \n| 1. Having less than high school education\n| <*Answer_8665*>\n| 2. Work limiting health conditions (illness / injury)\n| <*Answer_8666*>\n| 3. Lack of adequate job skills\n| <*Answer_8667*>\n| 4. Lack of job experience\n| Date Given: <.Date_Given.>\n| <*Answer_8668*>\n| 5. Transportation\n| <*Answer_8669*>\n| 6. Child care\n| <*Answer_8670*>\n| 7. Racial discrimination\n| <*Answer_8671*>\n| 8. Lack of information about jobs\n| <*Answer_8672*>\n| 9. Lack of stable housing\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8673*>\n| 10. Drug / alcohol addiction\n| <*Answer_8674*>\n| 11. Domestic violence\n| <*Answer_8675*>\n| 12. Physical disabilities\n| <*Answer_8676*>\n| 13. Mental illness\n| <*Answer_8677*>\n| 14. Fear of rejection\n| Location: <.Location.>\n| <*Answer_8678*>\n| 15. Lack of work clothing\n| <*Answer_8679*>\n| 16. No jobs in the community\n| <*Answer_8680*>\n| 17. No jobs that match my skills / training\n| <*Answer_8681*>\n| 18. Being a single parent\n| <*Answer_8682*>\n| 19. Need to take care of young children\n| \n| <*Answer_8683*>\n| 20. Cannot speak English very well\n| <*Answer_8684*>\n| 21. Cannot read or write very well\n| <*Answer_8685*>\n| 22. Problems with getting to job on time\n| <*Answer_8686*>\n| 23. Lack of confidence\n| <*Answer_8687*>\n| 24. Lack of support system\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_8688*>\n| 25. Lack of coping skills for daily struggles\n| <*Answer_8689*>\n| 26. Anger management\n| <*Answer_8690*>\n| 27. Past criminal record\n| <*Answer_8691*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| SSN: <.Patient_SSN.>\n|results should be verified for accuracy and used in conjuncion with \n|other diagnostic activities.\n|\n|Copyright @2017 Loyola University Chicago All Rights Reserved\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["211", "PEBS-20\n", "\n|Short Perceived Employment Barriers Scale (PEBS-20)\n| Gender: <.Patient_Gender.>\n|<*Answer_7771*> \n| \n| The range for the total score and each subscale is 1-5. \n| Higher scores indicate higher perception of Employment Barriers.\n| \n| If the Veteran completed the Employment Hope Scale (EHS-14) today, you\n| can use that to calculate the Psychological Self-Sufficiency Score by \n| subtracting the PEBS total score from the EHS total score.\n| \n| \n| \n|Questions and Answers:\n|\n| PHYSICAL & MENTAL HEALTH\n| 7. Drug / alcohol addiction\n| <*Answer_8674*>\n| 8. Domestic violence\n| <*Answer_8675*>\n| 9. Physical disabilities\n| <*Answer_8676*>\n| Date Given: <.Date_Given.>\n| 10. Mental illness\n| <*Answer_8677*>\n|\n| LABOR MARKET EXCLUSION\n| 11. Lack of work clothing\n| <*Answer_8679*>\n| 12. No jobs in the community\n| <*Answer_8680*>\n| 13. No jobs that match my skills / training\n| <*Answer_8681*>\n| Clinician: <.Staff_Ordered_By.>\n| \n| CHILD CARE\n| 5. Child care\n| <*Answer_8670*>\n| 14. Being a single parent\n| <*Answer_8682*>\n| 15. Need to take care of young children\n| <*Answer_8683*>\n| \n| HUMAN CAPITAL\n| Location: <.Location.>\n| 1. Having less than high school education\n| <*Answer_8665*>\n| 2. Work limiting health conditions (illness / injury)\n| <*Answer_8666*>\n| 3. Lack of adequate job skills\n| <*Answer_8667*>\n| 4. Lack of job experience\n| <*Answer_8668*>\n| 6. Lack of information about jobs\n| <*Answer_8672*>\n| \n| \n| SOFT SKILLS\n| 16. Problems with getting to job on time\n| <*Answer_8686*>\n| 17. Lack of confidence\n| <*Answer_8687*>\n| 18. Lack of support system\n| <*Answer_8688*>\n| 19. Lack of coping skills for daily struggles\n| <*Answer_8689*>\n| Veteran: <.Patient_Name_Last_First.>\n| 20. Anger management\n| <*Answer_8690*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright @2017 Loyola University Chicago All Rights Reserved\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["212", "WBS\n", "\n|Well-Being Signs (WBS)\n| Gender: <.Patient_Gender.>\n| \n| WBS Average Score: <*Answer_7771*>\n| \n| \n|Questions and Answers:\n|\n| Over the past 3 months what percentage of the time have you been:\n| \n| 1. Fully satisfied with how things are going in these aspects of life?\n| \n| <*Answer_8692*>\n| 2. Regularly involved in all aspects of life that are important to you?\n| <*Answer_8693*>\n| 3. Functioning your best in aspects of life that you do participate in?\n| <*Answer_8694*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["213", "ASRS-6\n", "\n|Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>\n| \n| ASRS-6 screening score = <-Total->\n| \n| The total score range is between 0 and 25. A score of 14 or higher is \n| considered clinically significant, indicating the need for additional \n| assessment. This test is intended for use as a screening tool only and \n| should not be used in isolation to diagnose ADHD without additional \n| supporting evidence such as collateral information, academic/occupational \n|for DSM-5 (ASRS-6)\n| records, and a thorough psychosocial history. For the purposes of \n| diagnosing ADHD, cognitive testing has decreased reliability and \n| validity and is not required for diagnosis and treatment.\n| \n|\n|Questions and Answers:\n| \n| 1. How often do you have difficulty concentrating on what people say to \n| you, even when they are speaking to you directly?\n| <*Answer_8695*>\n| \n| 2. How often do you leave your seat in meetings or other situations in \n| which you are expected to remain seated?\n| <*Answer_8696*>\n| 3. How often do you have difficulty unwinding and relaxing when you have \n| time to yourself?\n| <*Answer_8697*>\n| 4. When you're in a conversation, how often do you find yourself \n| finishing the sentences of the people you are talking to before they \n| can finish them themselves?\n| <*Answer_8698*>\n| Date Given: <.Date_Given.>\n| 5. How often do you put things off until the last minute?\n| <*Answer_8699*>\n| 6. How often do you depend on others to keep your life in order and \n| attend to details?\n| <*Answer_8700*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n
\n\n"], ["214", "DAR-5\n", "\n|Dimensions of Anger Reactions (DAR-5)\n| Gender: <.Patient_Gender.>\n| \n| DAR-5 Total Score = <-TOTAL->\n|\n| Scores can range from 5-25, with higher scores indicating worse \n| symptomatology. A total score of 12 or above suggests the patient \n| might benefit from further assessment and treatment by a mental health\n| clinician aimed at addressing their anger difficulties.\n| \n| \n| \n|Questions and Answers:\n| \n| 1. I found myself getting angry at people or situations.\n| <*Answer_8701*>\n| 2. When I got angry, I got really mad.\n| <*Answer_8702*>\n| 3. When I got angry, I stayed angry.\n| <*Answer_8703*>\n| 4. When I got angry at someone I wanted to hit them.\n| <*Answer_8704*>\n| Date Given: <.Date_Given.>\n| 5. My anger prevented me from getting along with people as well\n| as I'd have liked to.\n| <*Answer_8705*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["215", "EDE-Q\n", "\n|Eating Disorder Examination Questionnaire (EDE-Q)\n| Gender: <.Patient_Gender.>\n| 25 How dissatisfied have you been with your weight?\n| <*Answer_8730*>\n| 26 How dissatisfied have you been with your shape?\n| <*Answer_8731*>\n| 27 How uncomfortable have you felt seeing your body (for example, \n| seeing your shape in the mirror, in a shop window reflection, \n| while undressing or taking a bath or shower)?\n| <*Answer_8732*>\n| 28 How uncomfortable have you felt about others seeing your shape or\n| figure (for example, in communal changing rooms, when swimming, or \n| <*Answer_7771*>\n| wearing tight clothes)?\n| <*Answer_8733*>\n| What is your weight at present? (Please give your best estimate.)\n| <*Answer_8734*>\n| What is your height? (Please give your best estimate.)\n| <*Answer_8735*>\n| If female: Over the past three to four months have you missed any\n| menstrual periods?\n| <*Answer_8736*>\n| If so, how many?\n| \n| <*Answer_8737*>\n| Have you been taking the "pill"?\n| <*Answer_8738*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n||(c) 2008 Christopher G Fairburn and Sarah Beglin\n| Higher scores on the global scale and subscales denote more problematic\n| eating behaviors and attitudes. A global score of 4 or greater is\n| generally considered clinically significant. \n| \n| \n|Questions and Answers:\n| \n| \n| 1 Have you been deliberately trying to limit the amount of food you \n| eat to influence your shape or weight (whether or not you have \n| succeeded)?\n| <*Answer_8706*>\n| 2 Have you gone for long periods of time (8 waking hours or more) \n| without eating anything at all in order to influence your shape\n| or weight?\n| <*Answer_8707*>\n| 3 Have you tried to exclude from your diet any foods that you like \n| in order to influence your shape or weight (whether or not you have \n| Date Given: <.Date_Given.>\n| succeeded)?\n| <*Answer_8708*>\n| 4 Have you tried to follow definite rules regarding your eating (for \n| example, a calorie limit) in order to influence your shape or weight \n| (whether or not you have succeeded)?\n| <*Answer_8709*>\n| 5 Have you had a definite desire to have an empty stomach with the aim\n| of influencing your shape or weight?\n| <*Answer_8710*>\n| 6 Have you had a definite desire to have a totally flat stomach?\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8711*>\n| 7 Has thinking about food, eating or calories made it very difficult \n| to concentrate on things you are interested in (for example, working, \n| following a conversation, or reading)?\n| <*Answer_8712*>\n| 8 Has thinking about shape or weight made it very difficult to \n| concentrate on things you are interested in (for example, working, \n| following a conversation, or reading)?\n| <*Answer_8713*>\n| 9 Have you had a definite fear of losing control over eating?\n| Location: <.Location.>\n| <*Answer_8714*>\n| 10 Have you had a definite fear that you might gain weight?\n| <*Answer_8715*>\n| 11 Have you felt fat?\n| <*Answer_8716*>\n| 12 Have you had a strong desire to lose weight?\n| <*Answer_8717*>\n| 13 Over the past 28 days, how many times have you eaten what other \n| people would regards as an unusually large amount of food (given \n| the circumstances)?\n| \n| <*Answer_8718*>\n| 14 ... On how many of these times did you have a sense of having lost\n| control over your eating (at the time you were eating)?\n| <*Answer_8719*>\n| 15 Over the past 28 days, on how many DAYS have such episodes of \n| overeating occurred (i.e. you have eaten an unusually large amount \n| of food and have had a sense of loss of control at the time)?\n| <*Answer_8720*>\n| 16 Over the past 28 days, how many times have you made yourself sick \n| (vomit) as a means of controlling your shape or weight?\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_8721*>\n| 17 Over the past 28 days, how many times have you taken laxatives as \n| a means of controlling your shape or weight?\n| <*Answer_8722*>\n| 18 Over the past 28 days, how many times have you exercised in a \n| driven or compulsive way as a means of controlling your weight, \n| shape or amount of fat, or to burn off calories?\n| <*Answer_8723*>\n| 19 Over the past 28 days, on how many days have you eaten in secret \n| (ie, furtively)?\n| SSN: <.Patient_SSN.>\n| ... Do not count episodes of binge eating\n| <*Answer_8724*>\n| 20 On what proportion of the times that you have eaten have you felt \n| guilty (felt that you ve done wrong) because of its effect on your \n| shape or weight? \n| ... Do not count episodes of binge eating.\n| <*Answer_8725*>\n| 21 How concerned have you been about other people seeing you eat?\n| ... Do not count episodes of binge eating\n| <*Answer_8726*>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| 22 Has your weight influenced how you think about (judge) yourself \n| as a person?\n| <*Answer_8727*>\n| 23 Has your shape influenced how you think about (judge) yourself as \n| a person?\n| <*Answer_8728*>\n| 24 How much would it have upset you if you had been asked to weigh \n| yourself once a week (no more, or less, often) for the next four \n| weeks?\n| <*Answer_8729*>\n
\n\n"], ["216", "CIA\n", "\n|Clinical Impairment Assessment Questionnaire 3.0 (CIA)\n| Gender: <.Patient_Gender.>\n| <*Answer_7771*>\n| \n| Scores can range from 0 to 48 with a higher score being indicative of a \n| higher level of psychosocial impairment secondary to eating disorder \n| psychopathology. A score of 16 or greater may be used to predict eating \n| disorder case status.\n| \n| \n|Questions and Answers:\n| \n| \n| 1 ... made it difficult to concentrate?\n| <*Answer_8739*>\n| 2 ... made you feel critical of yourself?\n| <*Answer_8740*>\n| 3 ... stopped you going out with others?\n| <*Answer_8741*>\n| 4 ... affected your work performance (if applicable)?\n| <*Answer_8742*>\n| 5 ... made you forgetful?\n| Date Given: <.Date_Given.>\n| <*Answer_8743*>\n| 6 ... affected your ability to make everyday decisions?\n| <*Answer_8744*>\n| 7 ... interfered with meals with family or friends?\n| <*Answer_8745*>\n| 8 ... made you upset?\n| <*Answer_8746*>\n| 9 ... made you feel ashamed of yourself?\n| <*Answer_8747*>\n| 10 ... made it difficult to eat out with others?\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8748*>\n| 11 ... made you feel guilty?\n| <*Answer_8749*>\n| 12 ... interfered with you doing things you used to enjoy?\n| <*Answer_8750*>\n| 13 ... made you absent-minded?\n| <*Answer_8751*>\n| 14 ... made you feel a failure?\n| <*Answer_8752*>\n| 15 ... interfered with your relationships with others?\n| Location: <.Location.>\n| <*Answer_8753*>\n| 16 ... made you worry?\n| <*Answer_8754*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n||Copyright Bohn and Fairburn, 2008\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["218", "LVVFQ\n", "\n|Low Vision Visual Functioning Questionnaire (LVVFQ)\n| Gender: <.Patient_Gender.>\n| \n| LVVFQ Total Score = <-TOTAL->\n| \n| \n|Questions and Answers:\n| \n| 1. Read newspaper or magazine articles\n| <*Answer_8768*>\n| 2. Read mail\n| \n| <*Answer_8769*>\n| 3. Read menus\n| <*Answer_8776*>\n| 4. Read small print on package labels\n| <*Answer_8770*>\n| 5. Keep your place while reading\n| <*Answer_8771*>\n| 6. See photos\n| <*Answer_8784*>\n| 7. Find something on a crowded shelf\n| Date Given: <.Date_Given.>\n| <*Answer_8781*>\n| 8. Identify medicine\n| <*Answer_8778*>\n| 9. Tell time\n| <*Answer_8779*>\n| 10. Read street signs\n| <*Answer_8786*>\n| 11. Read print on TV\n| <*Answer_8783*>\n| 12. Watch TV\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8782*>\n| 13. Handle finances\n| <*Answer_8772*>\n| 14. Take a message\n| <*Answer_8773*>\n| 15. Prepare meals\n| <*Answer_8775*>\n| 16. Use appliance dials\n| <*Answer_8780*>\n| 17. Groom yourself\n| Location: <.Location.>\n| <*Answer_8777*>\n| 18. Eat and drink neatly\n| <*Answer_8774*>\n| 19. Get around outdoors in places you know\n| <*Answer_8785*>\n| 20. Adjust to bright light\n| <*Answer_8787*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["219", "FAST-ORIGINAL\n", "\n|Functional Assessment Staging\n| Gender: <.Patient_Gender.>\n| \n| \n| PLACEHOLDER FOR DEPRECATED FAST-ORIGINAL\n| \n| \n|Copyright (c) 1984 by Barry Reisberg, M.D., Reproduced with permission.\n| \n|Information contained in this note is based on a self-report assessment and is\nnot sufficient to use alone for diagnostic purposes. Assessment results\n| \nshould be verified for accuracy and used in conjunction with other diagnostic activities and procedures.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["22", "BRADEN SCALE\n", "\n|Braden Scale for Predicting Pressure Ulcer Risk\n| Gender: <.Patient_Gender.>\n|\n| Braden Scale Score: <-Braden Score->\n|\n| Severe risk: 9 or lower.\n| High risk: 10-12.\n| Moderate risk: 13-14.\n| Mild risk: 15-18.\n| \n|Questions and Answers\n|\n|\n| Sensory perception -- ability to respond meaningfully to pressure-related\n| discomfort\n| <*Answer_5427*>\n| Moisture -- degree to which skin is exposed to moisture\n| <*Answer_5428*>\n| Activity -- degree of physical activity\n| <*Answer_5429*>\n| Mobility -- ability to change and control body position\n| <*Answer_5430*>\n| Date Given: <.Date_Given.>\n| Nutrition -- usual food intake patterns\n| <*Answer_5431*>\n| Friction and shear\n| <*Answer_5432*>\n| \n|Information contained in this note is based on a self report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities. \n|\n| Clinician: <.Staff_Ordered_By.>\n|Copyright Barbara Braden & Nancy Bergstrom, 1988 $~\n| Location: <.Location.>\n|\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["220", "PROMIS10\n", "\n|Patient-Reported Outcomes Measurement Information System (PROMIS-10)\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>\n| \n|<*Answer_7771*>\n|\n|The PROMIS-10 measures patients' perceptions of their own physical and \n|mental health. It can assess the outcomes of many different types of \n|patient-centered innovations. It does this by assessing overall "global" \n|health.\n|\n|Global Health Scale\n|The mean (average) T-score of PROMIS-10 among the general U.S. population \n|is 50, with a standard deviation (SD) of 10. This applies to the Mental \n|Health and Physical Health subscales. Higher scores are better, so a score \n|above the mean of 50 is better than average and a score below the mean of \n|50 is worse than average.\n|\n| \n|Questions and Answers:\n| \n| 1) In general, would you say your health is:\n| \n| <*Answer_8789*>\n| 2) In general, would you say your quality of life is:\n| <*Answer_8790*>\n| 3) In general, how would you rate your physical health?\n| <*Answer_8791*>\n| 4) In general, how would you rate your mental health, including your\n| mood and your ability to think?\n| <*Answer_8792*>\n| 5) In general, how would you rate your satisfaction with your social \n| activities and relationships?\n| Date Given: <.Date_Given.>\n| <*Answer_8793*>\n| 6) In general, please rate how well you carry out your usual social \n| activities and roles. (This includes activities at home, at work \n| and in your community, and responsibilities as a parent, child, \n| spouse, employee, friend, etc.)\n| <*Answer_8794*>\n| 7) To what extent are you able to carry out your everyday physical \n| activities such as walking, climbing stairs, carrying groceries,\n| or moving a chair?\n| <*Answer_8795*>\n| Clinician: <.Staff_Ordered_By.>\n| 8) In the past 7 days... How often have you been bothered by emotional \n| problems such as feeling anxious, depressed or irritable?\n| <*Answer_8796*>\n| 9) How would you rate your fatigue on average?\n| <*Answer_8797*>\n| 10) How would you rate your pain on average?\n| <*Answer_8798*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| Location: <.Location.>\n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n
\n\n"], ["221", "SBAF\n", "\n|Safety Behavior Assessment Form (SBAF)\n| Gender: <.Patient_Gender.>\n| 33. Check that I can swallow without choking\n| <*Answer_8896*>\n| 34. Stay within certain distances from home (or other safe places)\n| <*Answer_8897*>\n| 35. Pay attention to body for physical symptoms or sensations\n| <*Answer_8898*>\n|\n| HEALTH ANXIETY\n|\n| 36. Call doctors' offices (or health-lines) frequently\n|\n| <*Answer_8899*>\n| 37. Check my body for problems (pain, discomfort, symmetry, discoloration, \n| new growth, etc.)\n| <*Answer_8900*>\n| 38. Research medical symptoms on the internet\n| <*Answer_8901*>\n| 39. Check my body temperature\n| <*Answer_8902*>\n| 40. Talk to others about my health or health-related activities\n| <*Answer_8903*>\n|<*Answer_7771*>\n| 41. Request specialized medical exams from providers\n| <*Answer_8904*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n| Higher scores suggest more frequent safety behavior usage.\n| \n| \n|Questions and Answers:\n| \n| VIGILANCE\n| \n|\n| 1. Scope places out before entering\n| <*Answer_8864*>\n| 2. Sit with back to wall\n| <*Answer_8865*>\n| 3. Rush through stores or go directly to desired items and leave as \n| quickly as possible\n| <*Answer_8866*>\n| 4. Check yard or the area around your home ("Perimeter Checks")\n| <*Answer_8867*>\n| Date Given: <.Date_Given.>\n| 5. Make up contingency plans in case someone is physically aggressive \n| or there is some kind of emergency\n| <*Answer_8868*>\n| 6. Walk slowly to let someone pass who is close behind\n| <*Answer_8869*>\n| 7. Watch others for signs of danger\n| <*Answer_8870*>\n| 8. Check locks on doors or windows\n| <*Answer_8871*>\n|\n| Clinician: <.Staff_Ordered_By.>\n| GENERALIZED ANXIETY\n|\n| 9. Over-plan for everyday events\n| <*Answer_8872*>\n| 10. Call or contact loved ones to make sure they are ok\n| <*Answer_8873*>\n| 11. Procrastinate before I start something or make a decision\n| <*Answer_8874*>\n| 12. Research things before I start or before making a decision\n| <*Answer_8875*>\n| Location: <.Location.>\n| 13. Try to do things perfectly\n| <*Answer_8876*>\n| 14. Monitor the clock\n| <*Answer_8877*>\n| 15. Ask others for reassurance (e.g., about a decision or worry)\n| <*Answer_8878*>\n|\n| SOCIAL ANXIETY\n|\n| 16. Monitor others' reactions to things I say\n| \n| <*Answer_8879*>\n| 17. Prepare things to say while others are talking\n| <*Answer_8880*>\n| 18. Talk through silences or talk so that silences do not occur\n| <*Answer_8881*>\n| 19. Be overly polite or agreeable\n| <*Answer_8882*>\n| 20. Attempt to hide anxiety (e.g., put hands in pocket because they are \n| shaking)\n| <*Answer_8883*>\n| Veteran: <.Patient_Name_Last_First.>\n| 21. Leave events or activities early\n| <*Answer_8884*>\n| 22. Make little eye contact\n| <*Answer_8885*>\n| 23. Respond to calls with text messages\n| <*Answer_8886*>\n| 24. Plan and/or rehearse what I am going to say ahead of time\n| <*Answer_8887*>\n| 25. Make myself look busy while at work or when out in public so that \n| others do not talk to me\n| SSN: <.Patient_SSN.>\n| <*Answer_8888*>\n| 26. Cut conversations short\n| <*Answer_8889*>\n| 27. Monitor what I say in conversations\n| <*Answer_8890*>\n| 28. Pretend I do not see or recognize someone so that I do not have to \n| speak with them\n| <*Answer_8891*>\n|\n| PANIC\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n|\n| 29. Take it easy when I exercise (or do other activities that require \n| physical exertion) so my heart rate does not get too high\n| <*Answer_8892*>\n| 30. Stay on the outside of crowds and/or monitor for exits or escape routes\n| <*Answer_8893*>\n| 31. Carry a medication in case I need it\n| <*Answer_8894*>\n| 32. Check my pulse or heart rate\n| <*Answer_8895*>\n\n\n"], ["222", "SBAF-PTSD\n", "\n|Safety Behavior Assessment Form - PTSD (SBAF-PTSD)\n| Gender: <.Patient_Gender.>\n| \n|<*Answer_7771*>\n|\n| Raw scores range from 0-30, with higher scores suggestive of more frequent \n| safety behavior usage.\n| \n| \n|Questions and Answers:\n| \n| \n| 1. Scope places out before entering\n| <*Answer_8905*>\n| 2. Sit with back to wall\n| <*Answer_8906*>\n| 3. Check yard or the area around your home ("Perimeter Checks")\n| <*Answer_8907*>\n| 4. Make up contingency plans in case someone is physically aggressive or\n| there is some kind of emergency\n| <*Answer_8908*>\n| 5. Walk slowly to let someone pass who is close behind\n| Date Given: <.Date_Given.>\n| <*Answer_8909*>\n| 6. Watch others for signs of danger\n| <*Answer_8910*>\n| 7. Check locks on doors or windows\n| <*Answer_8911*>\n| 8. Pretend I do not see or recognize someone so that I do not have to \n| speak with them\n| <*Answer_8912*>\n| 9. Cut conversations short\n| <*Answer_8913*>\n| Clinician: <.Staff_Ordered_By.>\n| 10. Leave events or activities early\n| <*Answer_8914*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n\n\n"], ["223", "GASS\n", "\n|Glasgow Antipsychotic Side-Effect Scale (GASS)\n| Gender: <.Patient_Gender.>\n| 21. Women only: I have noticed a change in my periods\n| <*Answer_8840*> \n| Level of distress: <*Answer_8841*>\n|\n| Weight Gain\n| 22. Men and women: I have been gaining weight\n| <*Answer_8842*> \n| Level of distress: <*Answer_8843*>\n| \n|Information contained in this note is based on a self-report assessment \n| \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| GASS Total Score = <-Total->\n|\n| Scores indicate the following side effect severity:\n| 0-21 absent/mild side effects\n| 22-42 moderate side effects\n| 43-63 severe side effects \n| \n|\n| \n|Questions and Answers:\n| \n| Please list current medication and total daily doses below: \n| <*Answer_8799*>\n|\n| Sedation and CNS Side Effects\n| 1. I felt sleepy during the day\n| <*Answer_8800*>\n| Level of distress: <*Answer_8801*>\n| 2. I felt drugged or like a zombie\n| Date Given: <.Date_Given.>\n| <*Answer_8802*> \n| Level of distress: <*Answer_8803*>\n|\n| Cardiovascular Side Effects\n| 3. I felt dizzy when I stood up and/or have fainted\n| <*Answer_8804*> \n| Level of distress: <*Answer_8805*>\n| 4. I have felt my heart beating irregularly or unusually fast\n| <*Answer_8806*> \n| Level of distress: <*Answer_8807*>\n| Clinician: <.Staff_Ordered_By.>\n|\n| Extra Pyramidal Side Effects\n| 5. My muscles have been tense or jerky\n| <*Answer_8808*> \n| Level of distress: <*Answer_8809*>\n| 6. My hands or arms have been shaky\n| <*Answer_8810*> \n| Level of distress: <*Answer_8811*>\n| 7. My legs have felt restless and/or I couldn't sit still\n| <*Answer_8812*> \n| Location: <.Location.>\n| Level of distress: <*Answer_8813*>\n| 8. I have been drooling\n| <*Answer_8814*> \n| Level of distress: <*Answer_8815*>\n| 9. My movements or walking have been slower than usual\n| <*Answer_8816*> \n| Level of distress: <*Answer_8817*>\n| 10. I have had uncontrollable movements of my face or body\n| <*Answer_8818*> \n| Level of distress: <*Answer_8819*>\n| \n|\n| Anticholinergic Side Effects\n| 11. My vision has been blurry\n| <*Answer_8820*> \n| Level of distress: <*Answer_8821*>\n| 12. My mouth has been dry\n| <*Answer_8822*> \n| Level of distress: <*Answer_8823*>\n| 13. I have had difficulty passing urine\n| <*Answer_8824*> \n| Veteran: <.Patient_Name_Last_First.>\n| Level of distress: <*Answer_8825*>\n|\n| Gastro-intestinal Side Effects\n| 14. I have felt like I am going to be sick or have vomited\n| <*Answer_8826*> \n| Level of distress: <*Answer_8827*>\n|\n| Genitourinary Side Effects\n| 15. I have wet the bed\n| <*Answer_8828*> \n| SSN: <.Patient_SSN.>\n| Level of distress: <*Answer_8829*>\n|\n| Screening Question for Diabetes Mellitus\n| 16. I have been very thirsty and/or passing urine frequently\n| <*Answer_8830*> \n| Level of distress: <*Answer_8831*>\n|\n| Prolactinaemic Side Effects\n| 17. The areas around my nipples have been sore and swollen\n| <*Answer_8832*> \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Level of distress: <*Answer_8833*>\n| 18. I have noticed fluid coming from my nipples\n| <*Answer_8834*> \n| Level of distress: <*Answer_8835*>\n| 19. I have had problems enjoying sex\n| <*Answer_8836*> \n| Level of distress: <*Answer_8837*>\n| 20. Men only: I have had problems getting an erection\n| <*Answer_8838*> \n| Level of distress: <*Answer_8839*>\n
\n\n"], ["224", "MIOS+B-IPF\n", "\n|Moral Injury Outcome Scale (MIOS+B-IPF)\n| Gender: <.Patient_Gender.>\n|\n|<*Answer_7771*> \n|\n| \n|Questions and Answers:\n| \n| Have you had at least one experience like this that troubles you \n| currently?\n| <*Answer_8922*>\n| \n| If yes, please check the type of experience that is most currently \n| distressing. If more than one, check all that apply.\n<*Answer_7772*>\n|\n| \n| MIOS\n|\n| 1. I blame myself.\n| <*Answer_8924*>\n| 2. I have lost faith in humanity.\n| Date Given: <.Date_Given.>\n| <*Answer_8925*>\n| 3. People would hate me if they really knew me.\n| <*Answer_8926*>\n| 4. I have trouble seeing goodness in others.\n| <*Answer_8927*>\n| 5. People don't deserve second chances.\n| <*Answer_8928*>\n| 6. I am disgusted by what happened.\n| <*Answer_8929*>\n| 7. I feel like I don't deserve a good life.\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8930*>\n| 8. I keep myself from having success.\n| <*Answer_8931*>\n| 9. I no longer believe there is a higher power.\n| <*Answer_8932*>\n| 10. I lost trust in others.\n| <*Answer_8933*>\n| 11. I am angry all the time.\n| <*Answer_8934*>\n| 12. I am not the good person I thought I was.\n| Location: <.Location.>\n| <*Answer_8935*>\n| 13. I have lost pride in myself.\n| <*Answer_8936*>\n| 14. I cannot be honest with other people.\n| <*Answer_8937*>\n|\n| B-IPF\n|\n| 1. Romantic relationships with spouse or partner \n| <*Answer_8938*>\n| \n| 2. Relationships with your children\n| <*Answer_8939*>\n| 3. Relationships with other family members \n| <*Answer_8940*>\n| 4. Friendships or socializing\n| <*Answer_8941*>\n| 5. Professional (work, education, training) \n| <*Answer_8942*>\n| 6. Hobbies and recreation activities that you do alone\n| <*Answer_8943*>\n| Veteran: <.Patient_Name_Last_First.>\n| 7. Hobbies and recreation activities that you do with others\n| <*Answer_8944*>\n| 8. Religious faith/spirituality\n| <*Answer_8945*>\n| 9. Day to day activities, such as chores, errands, finances, health\n| <*Answer_8946*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n| SSN: <.Patient_SSN.>\n|other diagnostic activities.\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["225", "MIDAS\n", "\n|Migraine Disability Assessment Test (MIDAS)\n| Gender: <.Patient_Gender.>\n| \n|<*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| 1. On how many days in the last 3 months did you miss work or school \n| because of your headaches?\n| <*Answer_8947*>\n| \n| 2. How many days in the last 3 months was your productivity at work or \n| school reduced by half or more because of your headaches? (Do not \n| include days you counted in question 1 where you missed work or \n| school.)\n| <*Answer_8948*>\n| 3. On how many days in the last 3 months did you not do household work \n| (such as housework, home repairs and maintenance, shopping, caring \n| for children and relatives) because of your headaches?\n| <*Answer_8949*>\n| 4. How many days in the last 3 months was your productivity in household\n| Date Given: <.Date_Given.>\n| work reduced by half of more because of your headaches? (Do not \n| include days you counted in question 3 where you did not do household \n| work.)\n| <*Answer_8950*>\n| 5. On how many days in the last 3 months did you miss family, social or \n| leisure activities because of your headaches?\n| <*Answer_8951*>\n|\n| A. On how many days in the last 3 months did you have a headache? (If a \n| headache lasted more than 1 day, count each day.)\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_8952*>\n| B. On a scale of 0 - 10, on average how painful were these headaches? \n| (where 0=no pain at all, and 10=pain as bad as it can be.)\n| <*Answer_8953*> \n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n||(c) Innovative Medical Research 1997\n| Location: <.Location.>\n|(c) 2007, AstraZeneca Pharmaceuticals, LP. All Rights reserved.\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["226", "HIT-6\n", "\n|Headache Impact Test (HIT-6)\n| Gender: <.Patient_Gender.>\n|\n| \n| HIT-6 Total Score = <-Total->\n|\n| The HIT-6 total score ranges between 36 and 78, with larger scores\n| reflecting greater impact. Scores over 50 may indicate significant\n| impact on functioning.\n| \n| \n| \n|Questions and Answers:\n| \n| 1. When you have headaches, how often is the pain severe?\n| <*Answer_8954*>\n| 2. How often do headaches limit your ability to do usual daily\n| activities including household work, work, school, or social \n| activities?\n| <*Answer_8955*>\n| 3. When you have a headache, how often do you wish you could lie down?\n| <*Answer_8956*>\n| Date Given: <.Date_Given.>\n| 4. In the past 4 weeks, how often have you felt too tired to do work or\n| daily activities because of your headaches?\n| <*Answer_8957*>\n| 5. In the past 4 weeks, how often have you felt fed up or irritated \n| because of your headaches?\n| <*Answer_8958*>\n| 6. In the past 4 weeks, how often did headaches limit your ability to\n| concentrate on work or daily activities?\n| <*Answer_8959*>\n| \n| Clinician: <.Staff_Ordered_By.>\n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n||(c) 2001 QualityMetric, Inc. and GlaxoSmithKline Group of Companies.\n|All rights reserved.\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["227", "FSS\n", "\n|Fatigue Severity Scale (FSS)\n| Gender: <.Patient_Gender.>\n| \n| FSS Total Score = <-Total->\n| \n| Scores can range from 9-63, with higher scores indicative of more \n| severe fatigue.\n| \n| \n|Questions and Answers:\n| \n| \n| 1. My motivation is lower when I am fatigued.\n| <*Answer_8965*>\n| 2. Exercise brings on my fatigue.\n| <*Answer_8966*>\n| 3. I am easily fatigued.\n| <*Answer_8967*>\n| 4. Fatigue interferes with my physical functioning.\n| <*Answer_8968*>\n| 5. Fatigue causes frequent problems for me.\n| <*Answer_8969*>\n| Date Given: <.Date_Given.>\n| 6. My fatigue prevents sustained physical functioning.\n| <*Answer_8970*>\n| 7. Fatigue interferes with carrying out certain duties and \n| responsibilities.\n| <*Answer_8971*>\n| 8. Fatigue is among my three most disabling symptoms.\n| <*Answer_8972*>\n| 9. Fatigue interferes with my work, family, or social life.\n| <*Answer_8973*>\n| \n| Clinician: <.Staff_Ordered_By.>\n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n|Copyright 1989 American Medical Association. All rights reserved.\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["228", "MRC\n", "\n|Medical Research Council Breathlessness Scale (MRC)\n| Gender: <.Patient_Gender.>\n| \n| MRC Grade <-Total->\n| \n| \n|Questions and Answers:\n| \n| 1. Are you ever troubled by breathlessness except on strenuous \n| exertion?\n| <*Answer_8974*>\n| \n| 2. Are you short of breath when hurrying on the level or walking up\n| a slight hill?\n| <*Answer_8975*>\n| 3. Do you have to walk slower than most people on the level? -or-\n| Do you have to stop after a mile or so (or after 1/4 hour) on the \n| level at your own pace?\n| <*Answer_8976*>\n| 4. Do you have to stop for breath after walking about 100 yds. (or \n| after a few minutes) on the level?\n| <*Answer_8977*>\n| Date Given: <.Date_Given.>\n| 5. Are you too breathless to leave the house, or breathless after \n| undressing?\n| <*Answer_8978*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["229", "C19-YRS\n", "\nModified COVID-19 Yorkshire Rehabilitation Screening (C19-YRS)\n| Gender: <.Patient_Gender.>\n|\n<*Answer_7771*>\n|\n|\n<*Answer_7772*>\n|\n|Information contained in this note is based on a self-report assessment\n|and is not sufficient to use alone for diagnostic purposes. Assessment\n|results should be verified for accuracy and used in conjunction with\n|\n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n|\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["23", "MORSE FALL SCALE\n", "\n.|.|Morse Fall Scale||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>|| Morse Fall Scale Score: <-Morse Score->||No risk: 0-24|Low risk: 25-44|High risk: 45 and higher||Questions and Answers|History of falling: immediate or \nwithin 3 months?| <*Answer_3910*>|Secondary diagnosis:| <*Answer_3911*>|Ambulatory aid:| <*Answer_3912*>|Intravenous therapy/Heparin lock:| <*Answer_3913*>|Gait/Transferring:| \n<*Answer_3914*>|Mental Status:| <*Answer_3915*>| |Copyright Janice M. Morse, 1996 $~\n
\n\n"], ["230", "EQ-5D-5L\n", "\n|EuroQol Group 5-Dimension 5-Level Health Questionnaire (EQ-5D-5L)\n| Gender: <.Patient_Gender.>\n| \n| Health State = <*Answer_7771*>\n| EQ VAS = <-EQ VAS->\n| \n| \n|Questions and Answers:\n| \n| 1. MOBILITY\n| <*Answer_9049*>\n| \n| 2. SELF-CARE\n| <*Answer_9050*>\n| 3. USUAL ACTIVITIES (e.g. work, study, housework, family or leisure\n| activities)\n| <*Answer_9051*>\n| 4. PAIN / DISCOMFORT\n| <*Answer_9052*>\n| 5. ANXIETY / DEPRESSION\n| <*Answer_9053*>\n| 6. YOUR HEALTH TODAY \n| Date Given: <.Date_Given.>\n| <*Answer_9054*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["231", "PCFS\n", "\n|Post-COVID-19 Functional Status Scale (PCFS)\n| Gender: <.Patient_Gender.>\n| \n| PCFS Scale Grade = <-PCFS->\n|\n| Grade 0 = No functional limitations\n| Grade 1 = Negligible functional limitations\n| Grade 2 = Slight functional limitations\n| Grade 3 = Moderate functional limitations\n| Grade 4 = Severe functional limitations\n| \n| \n|Questions and Answers:\n| \n| 1. Can you live alone without any assistance from another person? \n| (e.g. independently being able to eat, walk, use the toilet and \n| manage routine daily hygiene)\n| <*Answer_9055*>\n| 2. Are there duties/activities at home or at work which you are no \n| longer able to perform yourself?\n| <*Answer_9056*>\n| 3. Do you suffer from symptoms, pain, depression or anxiety?\n| Date Given: <.Date_Given.>\n| <*Answer_9057*>\n| 4. Do you need to avoid or reduce duties/activities or spread these \n| over time?\n| <*Answer_9058*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["24", "BAM\n", "\n|.|.|Brief Addiction Monitor||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \ndid 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 \nglass of wine.] | <*Answer_5278*>|6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?| <*Answer_5279*>|7. In the past 30 days, \nhow many days did you use any of the following drugs: | 7A. Marijuana (cannabis, pot, weed)?| <*Answer_5280*>| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, \nPhenobarbital, downers, etc.)?| <*Answer_5281*>| 7C. Cocaine and/or Crack?| <*Answer_5282*>| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal \nmeth, ice, etc.)?| <*Answer_5283*>| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2, 3, 4), Percocet, Vicodin, Fentanyl, etc.)?| <*Answer_5284*>| 7F. \nInhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_5285*>| 7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other \nover-the-counter or unknown medications)?| <*Answer_5286*>|8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?| <*Answer_5287*>|9. How \nconfident are you that you will NOT use alcohol and drugs in the next 30 days?| <*Answer_5288*>|10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support \nyour recovery?| <*Answer_5289*>|11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., \naround risky "people, places or things")?| <*Answer_5290*>|12. Does your religion or spirituality help support your recovery?| <*Answer_5291*>|13. In the past 30 days, how many days did you \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Clinical Subscales| Use: <-Use->| Items 4, 5, 6. A high score indicates more use, range is 0 to 12. If a patient scores a 1 \nspend much of the time at work, school, or doing volunteer work?| <*Answer_5292*>|14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food \nand clothing for yourself and your dependents?| <*Answer_5293*>|15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?| \n <*Answer_5294*>|16. In the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?| <*Answer_5295*>|17. How satisfied \nare you with your progress toward achieving your recovery goals?| <*Answer_5296*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| |$~\nor 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, \n2, 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 \ntreatment 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. \nClinicians are encouraged to consider scores on individual Protective items in offering interventions as indicated during initial treatment planning and following re-assessment.|||Questions and \nAnswers||A. Date of administration:| <*Answer_5272*>|B. Method of administration:| <*Answer_5273*>|1. In the past 30 days, how would you say your physical health has been?| \n<*Answer_5274*>|2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?| <*Answer_5275*>|3. In the past 30 days, how many days have you felt depressed, \nanxious, angry or very upset throughout most of the day?| <*Answer_5276*>|4. In the past 30 days, how many days did you drink ANY alcohol?| <*Answer_5277*>|5. In the past 30 days, how many days \n
\n\n"], ["25", "BASIS-R\n", "\n.|.|Behavior and Symptom Identification Scale - Revised||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<*Answer_3850*>|22. Did anyone talk to you about your drinking or drug use?| <*Answer_3851*>|23. Did you try to hide your drinking or drug use?| <*Answer_3852*>|24. Did you have problems from \nyour drinking or drug use?| <*Answer_3853*>|39. How old are you?| <*Answer_3854*>|40. What is your sex?| <*Answer_3855*>|41. Are you . . .| <*Answer_3856*>|42. What is your race?| \n<*Answer_3857*>|43. What is your first language?| <*Answer_3858*>|44. How much school have you completed?| <*Answer_3859*>|45. Are you now. . .| <*Answer_3860*>|46. Outside of your treatment \nproviders, what is your main source of social support?| <*Answer_3861*>|47. Where did you sleep in the past 30 days? (Check one or more)| <*Answer_3862*>|Specify Other:| <*Answer_3863*>|48. \nAt any time in the past 30 days, did you work at a paying job?| <*Answer_3864*>|49. At any time in the past 30 days, did you work at a volunteer job?| <*Answer_3865*>|50. At any time in the \npast 30 days, were you a student in a high school, job training or college degree program?| <*Answer_3866*>|51. Do you now receive disability benefits; for example, SSI, SSDI or other disability \ninsurance? (Check one or more)| <*Answer_3867*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment \nresults should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |Basis-R| Depression and Functioning: <-Depression and Functioning->| Interpersonal Problems: \n<-Interpersonal Problems->| Psychotic Symptoms: <-Psychotic Symptoms->| Alcohol/Drug Use: <-Alcohol/Drug Use->| Emotional Lability: <-Emotional Lability->| Self-Harm: <-Self-Harm->| \nOverall: <-Overall->||Questions and Answers||1. Managing your day-to-day life?| <*Answer_3830*>|2. Coping with problems in your life?| <*Answer_3831*>|3. Concentrating?| <*Answer_3832*>|4. \nGet along with people in your family?| <*Answer_3833*>|5. Get along with people outside your family?| <*Answer_3834*>|6. Get along well in social situations?| <*Answer_3835*>|7. Feel close \nto another person?| <*Answer_3836*>|8. Feel like you had someone to turn to if you needed help?| <*Answer_3837*>|9. Feel confident in yourself?| <*Answer_3838*>|10. Feel sad or depressed?| \n <*Answer_3839*>|11. Think about ending your life?| <*Answer_3840*>|12. Feel nervous?| <*Answer_3841*>|13. Have thoughts racing through your head?| <*Answer_3842*>|14. Think you had special \npowers?| <*Answer_3843*>|15. Hear voices or see things?| <*Answer_3844*>|16. Think people were watching you?| <*Answer_3845*>|17. Think people were against you?| <*Answer_3846*>|18. Have \nmood swings?| <*Answer_3847*>|19. Feel short-tempered?| <*Answer_3848*>|20. Think about hurting yourself?| <*Answer_3849*>|21. Did you have an urge to drink alcohol or take street drugs?| \n
\n\n"], ["26", "WAI-SR\n", "\n.|.|Working Alliance Inventory-Short Revised ||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |WAI-SR| Task Scale: <-Task Scale->| Bond Scale: <-Bond Scale->| Goal Scale: <-Goal Scale->||Questions and Answers||1. As \na result of these sessions I am clearer as to how I might be able to change.| <*Answer_5434*>|2. What I am doing in therapy gives me new ways of looking at my problem.| <*Answer_5435*>|3. I \nbelieve my therapist likes me.| <*Answer_5436*>|4. My therapist and I collaborate on setting goals for my therapy.| <*Answer_5437*>|5. My therapist and I respect each other.| \n<*Answer_5438*>|6. My therapist and I are working towards mutually agreed upon goals.| <*Answer_5439*>|7. I feel that my therapist appreciates me.| <*Answer_5440*>|8. My therapist and I agree \non what is important for me to work on.| <*Answer_5441*>|9. I feel my therapist cares about me even when I do things that he/she does not approve of.| <*Answer_5442*>|10. I feel that the things \nI do in therapy will help me to accomplish the changes that I want.| <*Answer_5443*>|11. My therapist and I have established a good understanding of the kind of changes that|would be good for me.| \n <*Answer_5444*>|12. I believe the way we are working with my problem is correct.| <*Answer_5445*>||Copyright (c) A. O. Horvath, 1981, 1982; Revision Tracey & Kokotowitc 1989|| $~\n
\n\n"], ["27", "PAS-EQUIP\n", "\n|Enhancing Quality of Care in Psychosis||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nyour doctor for mental health problems?| <*Answer_4429*>|26.Do you know the names of your medications that you are prescribed?| <*Answer_4430*>|27.Here is a list of medications you may be \nprescribed. Check all of the medications that you are currently prescribed.| <*Answer_4431*>|28.Over the past month, to what extent have you taken the medications prescribed by your doctor for \nmental health problems?| <*Answer_4432*>|29.What is your height: How many feet?| <*Answer_4433*>|How many inches:| <*Answer_4434*>|30.What is your weight in pounds?| \n<*Answer_4435*>|31.Have you been weighing yourself every week at home?| <*Answer_4436*>|32.Over the past month, have you gained or lost weight or stayed the same?| <*Answer_4437*>|33.How \nmuch weight have you gained?| <*Answer_4438*>|34.How much weight have you lost?| <*Answer_4439*>|35.Has your doctor recently talked with you about changing to medication that does not cause \nweight gain?| <*Answer_4440*>|36.Has your doctor recently recommended that you go to wellness or weight loss groups?| <*Answer_4441*>|37.How many times in the past month did you attend \nwellness or weight loss groups?| <*Answer_4442*>|39.Have you changed your diet in order to lose weight?| <*Answer_4443*>|40.Have you increased your physical activity recently in order to lose \nweight?| <*Answer_4444*>|41.Have you ever had angina, a heart attack, or a stroke?| <*Answer_4445*>|42.Do you currently have diabetes or hypertension, or are you being treated for diabetes or \nhypertension?| <*Answer_4455*>|43.Are you currently working in a job for pay?| <*Answer_4446*>|44.How many weeks have you worked at this job?| <*Answer_4447*>|45.How many hours a week do \nyou usually work?| <*Answer_4448*>|46.Is this a job that anyone can apply for, or is it only for disabled people?| <*Answer_4449*>|47.How many dollars did you earn last month?| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1.Managing your day-to-day life?| <*Answer_4405*>|2.Coping with problems in your life?| \n<*Answer_4450*>|48.Is this the total gross income from the job, or the amount of take-home pay from the job?| <*Answer_4456*>|49.Would you be interested in working at a paying job if it would \nnot affect your benefits too much and you could get the support you need?| <*Answer_4451*>|50.Has your doctor recently recommended that you go to the VA's work program---called "IPS" or \n"supported employment" ?| <*Answer_4452*>|51.How many times in the past month did you attend the VA's work program called IPS or supported employment?| <*Answer_4453*>|52.During the past \nmonth, how many job interviews have you gone to?| <*Answer_4454*>| $~\n<*Answer_4406*>|3.Concentrating?| <*Answer_4407*>|4.Get along with people in your family?| <*Answer_4408*>|5.Get along with people outside your family?| <*Answer_4409*>|6.Get along well \nin social situations?| <*Answer_4410*>|7.Feel close to another person?| <*Answer_4411*>|8.Feel like you had someone to turn to if you needed help?| <*Answer_4412*>|9.Feel confident in \nyourself?| <*Answer_4413*>|10.Feel sad or depressed?| <*Answer_4414*>|11.Think about ending your life?| <*Answer_4415*>|12.Feel nervous?| <*Answer_4416*>|13.Have thoughts racing \nthrough your head?| <*Answer_4417*>|14.Think you had special powers?| <*Answer_4418*>|15.Hear voices or see things?| <*Answer_4419*>|16.Think people were watching you?| \n<*Answer_4420*>|17.Think people were against you?| <*Answer_4421*>|18.Have mood swings?| <*Answer_4422*>|19.Feel short-tempered?| <*Answer_4423*>|20.Think about hurting yourself?| \n<*Answer_4424*>|21.Did you have an urge to drink alcohol or take street drugs?| <*Answer_4425*>|22.Did anyone talk to you about your drinking or drug use?| <*Answer_4426*>|23.Did you try to \nhide your drinking or drug use?| <*Answer_4427*>|24.Did you have problems from your drinking or drug use?| <*Answer_4428*>|25.Over the past month have you been prescribed any medication by \n
\n\n"], ["28", "NSI\n", "\n.|.|Neurobehavioral Symptom Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nactivities. $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||1. Feeling dizzy:| <*Answer_3868*>|2. Loss of balance:| <*Answer_3881*>|3. Poor coordination, \nclumsy:| <*Answer_3882*>|4. Headaches:| <*Answer_3883*>|5. Nausea:| <*Answer_3884*>|6. Vision problems, blurring, trouble seeing:| <*Answer_3885*>|7. Sensitivity to light:| \n<*Answer_3886*>|8. Hearing difficulty:| <*Answer_3887*>|9. Sensitivity to noise:| <*Answer_3888*>|10. Numbness or tingling on parts of my body:| <*Answer_3889*>|11. Change in taste and/or \nsmell:| <*Answer_3890*>|12. Loss of appetite or increase appetite:| <*Answer_3891*>|13. Poor concentration, can't pay attention, easily distracted:| <*Answer_3892*>|14. Forgetfulness, can't \nremember things:| <*Answer_3893*>|15. Difficulty making decisions:| <*Answer_3894*>|16. Slowed thinking, difficulty getting organized, can't finish things:| <*Answer_3895*>|17. Fatigue, loss \nof energy, getting tired easily:| <*Answer_3896*>|18. Difficulty falling or staying asleep:| <*Answer_3897*>|19. Feeling anxious or tense:| <*Answer_3898*>|20. Feeling depressed or sad:| \n<*Answer_3900*>|21. Irritability, easily annoyed:| <*Answer_3901*>|22. Poor frustration tolerance, feeling easily overwhelmed by things:| <*Answer_3902*>||Information contained in this note is \nbased 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 \n
\n\n"], ["29", "PTSD Status Form1\n", "\n.|.|PTSD Status Form||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \nof War?| <*Answer_3950*>|17. Did the veteran ever observe others or participate him/herself in atrocities, such as torturing prisoners, mutilating enemy bodies, or harming civilians? If veteran \nboth observed and participated, select "Participated." | <*Answer_3951*>|18. Has the veteran ever been hospitalized for treatment of an emotional or substance use problem, including war stress \n(PTSD)?| <*Answer_3952*>|19. Has the veteran ever received professional treatment as an outpatient for an emotional or substance use problem, including war stress (PTSD)?| <*Answer_3953*>|20. \nDuring the past 30 days, has the veteran been taking a prescribed medication for a psychological/emotional problem?| <*Answer_3954*>|21. Does the veteran have any chronic, medical problems (e.g., \ndiabetes, high blood pressure, epilepsy) which continue to interfere with his/her life?| <*Answer_3955*>|22. What is the highest level the veteran completed in school (e.g., completing high school \nis 12, GED is 12)?| <*Answer_3959*>|23. Is the veteran working now?| <*Answer_3962*>|23A. If "No," what is the major reason?| <*Answer_3963*>|24. Has the veteran ever been incarcerated \n(i.e., been in jail or prison) in his/her life?| <*Answer_3966*>|25. PTSD| <*Answer_3967*>|26. PTSS (subthreshold for PTSD)| <*Answer_3968*>|27. Alcohol Abuse/Dependence| \n<*Answer_3972*>|28. Drug Abuse/Dependence| <*Answer_3973*>|29. Anxiety Disorder (other than PTSD)| <*Answer_3974*>|30. Affective Disorder (other than Bipolar Disorder)| <*Answer_3975*>|31. \nBipolar Disorder| <*Answer_3976*>|32. Schizophrenia| <*Answer_3977*>|33. Psychosis (other than Schizophrenia)| <*Answer_3978*>|34. Other Axis I| <*Answer_3979*>|35. Personality Disorder| \n <*Answer_3980*>|36. What was the source of referral to your program?| <*Answer_3981*>|37. Has the veteran ever been treated before in a specialized PTSD program?| <*Answer_3982*>|38. Within \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1. Clinician's name| <*Answer_3930*>|2. Data entered by| <*Answer_4185*>|3. Date of admission for treatment| <*Answer_3931*>|4. Date of \nthe past 30 days, has the veteran experienced trouble controlling violent behavior (e.g., hitting someone)?| <*Answer_3983*>|39. Has the staff of your program verified the veteran's war zone \nservice by reference to the DD 214 or similar military records?| <*Answer_3984*>|40. Is the veteran being evaluated for PTSD due to sexual trauma which occurred during active duty?| \n<*Answer_3985*>|40A. Is the veteran being evaluated for PTSD due to sexual trauma which occurred before or after tour of active military duty?| <*Answer_3986*>|41. Is the veteran being evaluated \nfor PTSD due to noncombat nonsexual trauma which was incurred in the course of military duties?| <*Answer_3987*>|42. To what specialized program is this veteran being admitted?| \n<*Answer_3989*>| $~\ndata-entry| <*Answer_4186*>|5. Marital status| <*Answer_3938*>|6. Race/Ethnic ancestry| <*Answer_3939*>|7. For PTSD (Pre-1980: PTSD often diagnosed as Psychoneurosis)| <*Answer_3940*>|8. \nFor psychiatric, other than PTSD| <*Answer_3941*>|9. For medical, non-psychiatric| <*Answer_3942*>|10. For psychiatric (including PTSD)| <*Answer_5110*>|11. For physical| \n<*Answer_5111*>|12. Veteran's living arrangement at the time of admission to this program.| <*Answer_3946*>|12A. Is the veteran currently on an active tour of duty in the armed forces?| \n<*Answer_5094*>|12B. Is the veteran currently in the Reserves?| <*Answer_5095*>|12C. Is the veteran currently in the National Guard?| <*Answer_5100*>|13. Period of service. (Check all that \napply)| <*Answer_5097*>|Afghanistan| <*Answer_4004*>|Iraq| <*Answer_4005*>|13B. Did the veteran ever serve in the United States military in a peace-keeping operation (such as in Lebanon, \nSomalia, Bosnia, Kosovo)?| <*Answer_4006*>|14. Did the veteran ever serve in a war zone?| <*Answer_3948*>|14A. In what capacity did the veteran most recently serve in a war zone? (Check one \nbelow)| <*Answer_5098*>|15. Did the veteran receive friendly or hostile incoming fire from small arms, artillery, rockets, mortars or bombs?| <*Answer_3949*>|16. Was the veteran ever a Prisoner \n
\n\n"], ["3", "GDS DEMENTIA\n", "\n.|.|Global Deterioration Scale||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Dementia Stage: <-Stage->|| 1 = No cognitive decline | 2 = Very mild cognitive decline---Forgetful | 3 = Mild cognitive \ndecline---Early confusional | 4 = Moderate cognitive decline---Late confusional | 5 = Moderately severe cognitive decline---Early dementia | 6 = Severe cognitive decline---Middle dementia | 7 \n= Very severe cognitive decline---Late dementia ||Copyright (c) 1983 by Barry Reisberg, M.D. Reproduced with permission.||Information contained in this note is based on a self-report assessment and \nis 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.| $~\n
\n\n"], ["30", "PHQ-2\n", "\n.| .| Patient Health Questionnaire-2| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>||| PHQ-2 Depression Screening Score: <-Depression-> | <*Answer_999999999999*>| | \nQuestions and Answers| 1. Little interest or pleasure in doing things| <*Answer_4015*>| 2. Feeling down, depressed, or hopeless| <*Answer_4016*>| | | Information contained in \nthis 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 \ndiagnostic activities and procedures.| | (Kroenke, K., Spitzer, R. & Williams, J. 2003 The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care, 41, \n1284-1292). Copyright 1999 Pfizer Inc. All rights reserved. Reproduced with permission.| $~\n
\n\n"], ["31", "AUDC\n", "\n|Alcohol Use Disorders Identification Test - Consumption (AUDC)\n| Gender: <.Patient_Gender.>\n|\n|<*Answer_999999999999*> \n|\n|Questions and Answers\n| \n|1. How often did you have a drink containing alcohol in the past year?\n| Consider a drink to be a 12 ounce can or bottle of regular beer, \n| 8 ounces of malt liquor, a 5 ounce glass of table wine, or a\n| 1.5 ounce shot of liquor (like scotch, gin, or vodka).\n|\n| <*Answer_83*>\n|2. How many drinks containing alcohol did you have on a typical day when \n| you were drinking in the past year?\n| <*Answer_84*>\n|3. How often did you have six or more drinks on one occasion in the past year?\n| <*Answer_85*> \n|\n|Information contained in this note is based on a self report assessment and \n|is not sufficient to use alone for diagnostic purposes. Assessment results \n|should be verified for accuracy and used in conjunction with other diagnostic\n| Date Given: <.Date_Given.>\n|activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n|\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["315", "MDQ\n", "\n|Mood Disorder Questionnaire (MDQ)\n| Gender: <.Patient_Gender.>\n| \n| Mood Disorder Questionnaire\n| Possible Bipolar Disorder = <*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| 1. You felt so good or so hyper that other people thought you were not\n| your normal self or you were so hyper that you got into trouble?\n| \n| <*Answer_9074*>\n| 2. You were so irritable that you shouted at people or started fights or \n| arguments?\n| <*Answer_9075*>\n| 3. You felt much more self-confident than usual?\n| <*Answer_9076*>\n| 4. You got much less sleep than usual and found that you didn't really \n| miss it?\n| <*Answer_9077*>\n| 5. You were more talkative or spoke much faster than usual?\n| Date Given: <.Date_Given.>\n| <*Answer_9078*>\n| 6. Thoughts raced through your head or you couldn't slow your mind down?\n| <*Answer_9079*>\n| 7. You were so easily distracted by things around you that you had trouble\n| concentrating or staying on track?\n| <*Answer_9080*>\n| 8. You had more energy than usual?\n| <*Answer_9081*>\n| 9. Youwere much more active or did many more things than usual?\n| <*Answer_9082*>\n| Clinician: <.Staff_Ordered_By.>\n| 10. You were much more social or outgoing than usual, for example, you \n| telephoned friends in the middle of the night?\n| <*Answer_9083*>\n| 11. You were much more interested in sex than usual?\n| <*Answer_9084*>\n| 12. You did things that were unusual for you or that other people might\n| have thought were excessive, foolish, or risky?\n| <*Answer_9085*>\n| 13. Spending money got you or your family in trouble?\n| <*Answer_9086*>\n| Location: <.Location.>\n| 14. If you checked YES to more than one of the above, have several of\n| these ever happened during the same period of time?\n| <*Answer_9087*>\n| 15. How much of a problem did any of these cause you - like being unable \n| to work; having family, money, or legal troubles; getting into \n| arguments or fights?\n| <*Answer_9088*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["316", "PEG\n", "\n|Pain, Enjoyment, and General Activity (PEG)\n| Gender: <.Patient_Gender.>\n| \n| PEG Average Score = <-AVERAGE->\n| \n| \n|Questions and Answers:\n| \n| 1. What number best describes your pain on average in the past week?\n| <*Answer_9089*>\n| 2. What number best describes how, during the past week, pain has\n| \n| interfered with your enjoyment of life?\n| <*Answer_9090*>\n| 3. What number best describes how, during the past week, pain has\n| interfered with your general activity?\n| <*Answer_9091*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["317", "BAM-C-CBT-SUD\n", "\nBrief Addiction Monitor - Consumption Items for CBT-SUD (BAM-C-CBT-SUD)\n| Gender: <.Patient_Gender.>\n| \n| \n| Days Alcohol Use: <-Days Alcohol Use->\n| Days of Heavy Alcohol Use: <-Days Heavy Alcohol Use->\n| Days Other Drug Use: <-Days Other Drug Use->\n|\n| Range is 0 to 30. If a patient scores a 1 or greater, it calls for \n| further examination and clinical attention, e.g. consider addition of\n| pharmacotherapy or higher level of care, add motivational interviewing.\n| \n| \n| Questions and Answers\n| \n| A. Date of administration:\n| <*Answer_9092*>\n| B. Method of administration:\n| <*Answer_9093*>\n| \n| 1. Since the last session, how many days did you drink ANY alcohol?\n| <*Answer_9094*>\n| Date Given: <.Date_Given.>\n| \n| 2. Since the last session, how many days did you have at least 5 drinks\n| (if you are a man) or at least 4 drinks (if you are a woman)?\n| [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce\n| can/bottle of beer or 5-ounce glass of wine.]\n| <*Answer_9095*>\n| \n| 3. Since the last session, how many days did you use any illegal or\n| street drugs or abuse any prescription medications?\n| <*Answer_9096*>\n| Clinician: <.Staff_Ordered_By.>\n| \n| 4. Since the last session, how many days did you use any of the following\n| drugs: \n|\n| 4A. Marijuana (cannabis, pot, weed)?\n| <*Answer_9097*>\n| \n| 4B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, \n| Ambien, barbs, Phenobarbital, downers, etc.)?\n| <*Answer_9098*>\n| Location: <.Location.>\n| \n| 4C. Cocaine and/or Crack?\n| <*Answer_9099*>\n| \n| 4D. Other Stimulants (e.g., amphetamine, methamphetamine, Dexedrine,\n| Ritalin, Adderall, "speed", "crystal meth", "ice", etc.)?\n| <*Answer_9100*>\n| \n| 4E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, \n| codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n| \n| <*Answer_9101*>\n| \n| 4F. Inhalants (glues, adhesives, nail polish remover, paint thinner,\n| etc.)?\n| <*Answer_9102*>\n| \n| 4G. Other drugs (steroids, non-prescription sleep and diet pills,\n| Benadryl, Ephedra, other over-the-counter or unknown medications)?\n| <*Answer_9103*>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| \n| Information contained in this note is based on a self-report assessment\n and is not sufficient to use alone for diagnostic purposes. Assessment\n results should be verified for accuracy and used in conjunction with other\n diagnostic activities and procedures.\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["318", "BAM-R-CSG-SUD\n", "\n| Brief Addiction Monitor - Revised for CSG-SUD (BAM-R-CSG-SUD)\n| Gender: <.Patient_Gender.>\n| \n| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine\n| (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n| <*Answer_9122*>\n| \n| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?\n| <*Answer_9123*>\n| \n| 7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl,\n| Ephedra, other over-the-counter or unknown medications)?\n| \n| <*Answer_9124*>\n| \n| 8. In the past 30 days, how much were you bothered by cravings or urges to\n| drink alcohol or use drugs?\n| <*Answer_9107*>\n| \n| 9. How confident are you that you will NOT use alcohol and drugs in the\n| next 30 days?\n| <*Answer_9108*>\n| \n| \n| 10. In the past 30 days, how many days did you attend self-help meetings like\n| AA or NA to support your recovery?\n| <*Answer_9125*>\n| \n| 11. In the past 30 days, how many days were you in any situations or with\n| any people that might put you at an increased risk for using alcohol or\n| drugs (i.e., around risky "people, places or things")?\n| <*Answer_9126*>\n| \n| 12. Does your religion or spirituality help support your recovery?\n|Clinical Subscales\n| <*Answer_9109*>\n| \n| 13. In the past 30 days, how many days did you spend much of the time at\n| work, school, or doing volunteer work?\n| <*Answer_9127*>\n| \n| 14. Do you have enough income (from legal sources) to pay for necessities\n| such as housing, transportation, food and clothing for yourself and your\n| dependents?\n| <*Answer_9110*>\n|\n| \n| 15. In the past 30 days, how much have you been bothered by arguments or\n| problems getting along with any family members or friends?\n| <*Answer_9111*>\n| \n| 16. In the past 30 days, how many days did you contact or spend time with\n| any family members or friends who are supportive of your recovery?\n| <*Answer_9128*>\n| \n| 17. How satisfied are you with your progress toward achieving your recovery\n| Use: <-Use->\n| goals?\n| <*Answer_9112*>\n| \n| \n| Information contained in this note is based on a self-report assessment\n and is not sufficient to use alone for diagnostic purposes. Assessment\n results should be verified for accuracy and used in conjunction with other\n diagnostic activities and procedures.\n| Items 4, 5A, 6. A high score indicates more use, range is 0 to 90. If a\n| patient scores a 1 or greater, it calls for further assessment and clinical\n| attention, e.g., consider addition/change of pharmacotherapy or\n| psychosocial intervention.\n| \n|\n| Risk Factors: <-Risk Factors->\n| Items 1, 2, 3, 8, 11, 15. A high score indicates increased risk, range is 0\n| to 180. For subscale scores, items with ordinal response options (0-4) were\n| converted to contribute proportionately consistent with items on days of\n| use (0-30). Clinicians are encouraged to consider scores on individual\n| Risk items in offering interventions as indicated during initial treatment \n| planning and following re-assessment.\n|\n| Protective Factors: <-Protective Factors->\n| Date Given: <.Date_Given.>\n| Items 9, 10, 12, 13, 14, 16. A high score indicates greater protective\n| factors, range is 0 to 180. For subscale scores, items with ordinal\n| response options (0-4) were converted to contribute proportionately\n| consistent with items on days of use (0-30). Clinicians are encouraged\n| to consider scores on individual Protective items in offering interventions\n| as indicated during initial treatment planning and following re-assessment.\n|\n| Average Drinks (5B): <*Answer_9129*>\n| Highest Consumed (5C): <*Answer_9130*>\n| Items 5B and 5C should be reviewed and interpreted at the item-level and\n| Clinician: <.Staff_Ordered_By.>\n| are not included in any composite scores. These items provide additional, \n| clinically useful information about quantity of alcohol use that users are \n| encouraged to review and monitor, in addition to the frequency of use, risk \n| and protective composite scores, to inform treatment planning and treatment \n| progress.\n| \n|\n| Questions and Answers \n|\n| A. Date of administration:\n| Location: <.Location.>\n| <*Answer_9104*>\n| \n| B. Method of administration:\n| <*Answer_9105*>\n| \n| 1. In the past 30 days, how would you say your physical health has been?\n| <*Answer_9106*>\n| \n| 2. In the past 30 days, how many nights did you have trouble falling asleep\n| or staying asleep?\n| \n| <*Answer_9113*>\n|\n| 3. In the past 30 days, how many days have you felt depressed, anxious,\n| angry or very upset throughout most of the day?\n| <*Answer_9114*>\n| \n| 4. In the past 30 days, how many days did you drink ANY alcohol?\n| <*Answer_9115*>\n| \n| 5A. In the past 30 days, how many days did you have at least 5 drinks (if\n| Veteran: <.Patient_Name_Last_First.>\n| you are a man) or at least 4 drinks (if you are a woman)?\n| [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce\n| can/bottle of beer or 5-ounce glass of wine.]\n| <*Answer_9116*>\n| \n| 5B. In the past 30 days, on the days that you consumed alcohol, what was the\n| average number of drinks you consumed on those days?\n| <*Answer_9129*>\n| \n| 5C. In the past 30 days, on the days that you consumed alcohol, what was the\n| SSN: <.Patient_SSN.>\n| highest number of drinks you consumed in one day?\n| <*Answer_9130*>\n| \n| 6. In the past 30 days, how many days did you use any illegal or street\n| drugs or abuse any prescription medications?\n| <*Answer_9117*>\n| \n| 7A. Marijuana (cannabis, pot, weed)?\n| <*Answer_9118*>\n| \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien,\n| barbs, Phenobarbital, downers, etc.)?\n| <*Answer_9119*>\n| \n| 7C. Cocaine and/or Crack?\n| <*Answer_9120*>\n| \n| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin,\n| Adderall, speed, crystal meth, ice, etc.)?\n| <*Answer_9121*>\n
\n\n"], ["319", "BAM-IOP-CSG-SUD\n", "\n Brief Addiction Monitor: IOP version for CSG-SUD (BAM-IOP-CSG-SUD)\n| Gender: <.Patient_Gender.>\n| <*Answer_9144*>\n| 7G. Other drugs (steroids, non-prescription sleep and diet pills, \n| Benadryl, Ephedra, other over-the-counter or unknown\n| medications)?\n| <*Answer_9145*>\n| \n| 8. In the past 7 days, how much were you bothered by cravings or urges\n| to drink alcohol or use drugs?\n| <*Answer_9146*>\n| \n| \n| 9. How confident are you that you will NOT use alcohol and drugs in the\n| next 7 days?\n| <*Answer_9147*>\n| \n| 10. In the past 7 days, how many days did you attend self-help meetings\n| like AA or NA to support your recovery?\n| <*Answer_9148*>\n| \n| 11. In the past 7 days, how many days were you in any situations or with \n| any people that might put you at an increased risk for using alcohol\n| \n| or drugs (i.e., around risky "people, places or things")?\n| <*Answer_9149*>\n| \n| 12. Does your religion or spirituality help support your recovery?\n| <*Answer_9150*>\n| \n| 13. In the past 7 days, how many days did you spend much of the time at\n| work, school, or doing volunteer work?\n| <*Answer_9151*>\n| \n| Clinical Subscales:\n| 14. Do you have enough income (from legal sources) to pay for necessities\n| such as housing, transportation, food and clothing for yourself and\n| your dependents?\n| <*Answer_9152*>\n| \n| 15. In the past 7 days, how much have you been bothered by arguments or \n| problems getting along with any family members or friends?\n| <*Answer_9153*>\n| \n| 16. In the past 7 days, how many days did you contact or spend time with\n| \n| any family members or friends who are supportive of your recovery?\n| <*Answer_9154*>\n| \n| 17. How satisfied are you with your progress toward achieving your\n| recovery goals?\n| <*Answer_9155*>\n| \n| Information contained in this note is based on a self-report assessment\n and is not sufficient to use alone for diagnostic purposes. Assessment\n results should be verified for accuracy and used in conjunction with other\n| Use: <-Use->\n diagnostic activities and procedures.\n| Items 4, 5A, 6. A high score indicates more use, range is 0 to 12. If\n| a patient scores a 1 or greater, it calls for further assessment and \n| clinical attention, e.g., consider addition/change of pharmacotherapy\n| or psychosocial intervention.\n| \n| \n| Risk Factors: <-Risk Factors->\n| Items 1, 2, 3, 8, 11, 15. A high score indicates increased risk, range\n| is 0 to 24. Clinicians are encouraged to consider scores on individual\n| Risk items in offering interventions as indicated during initial \n| treatment planning and following re-assessment.\n| \n| Protective Factors: <-Protective Factors->\n| Items 9, 10, 12, 13, 14, 16. A high score indicates greater protective\n| factors, range is 0 to 24. Clinicians are encouraged to consider\n| Date Given: <.Date_Given.>\n| scores on individual Protective items in offering interventions as \n| indicated during initial treatment planning and following\n| re-assessment.\n|\n| Average Drinks (5B): <*Answer_9156*> \n| Highest Consumed (5C): <*Answer_9157*>\n| Items 5B and 5C should be reviewed and interpreted at the item-level \n| and are not included in any composite scores. These items provide \n| additional, clinically useful information about quantity of alcohol\n| use that users are encouraged to review and monitor, in addition to \n| Clinician: <.Staff_Ordered_By.>\n| the frequency of use, risk and protective composite scores, to inform \n| treatment planning and treatment progress.\n| \n| Questions and Answers\n| \n| A. Date of administration:\n| <*Answer_9131*>\n| B. Method of administration:\n| <*Answer_9132*>\n| \n| Location: <.Location.>\n| 1. In the past 7 days, how would you say your physical health has been?\n| <*Answer_9133*>\n| \n| 2. In the past 7 days, how many nights did you have trouble falling\n| asleep or staying asleep?\n| <*Answer_9134*>\n| \n| 3. In the past 7 days, how many days have you felt depressed, anxious,\n| angry or very upset throughout most of the day?\n| <*Answer_9135*>\n| \n| \n| 4. In the past 7 days, how many days did you drink ANY alcohol?\n| <*Answer_9136*>\n| \n| 5A. In the past 7 days, how many days did you have at least 5 drinks (if \n| you are a man) or at least 4 drinks (if you are a woman)?\n| [One drink is considered one shot of hard liquor (1.5 oz.) or\n| 12-ounce can/bottle of beer or 5 ounce glass of wine.]\n| <*Answer_9137*>\n|\n| Veteran: <.Patient_Name_Last_First.>\n| 5B. In the past 7 days, on the days that you consumed alcohol, what was\n| the average number of drinks you consumed on those days?\n| <*Answer_9156*>\n| \n| 5C. In the past 7 days, on the days that you consumed alcohol, what was \n| the highest number of drinks you consumed in one day?\n| <*Answer_9157*>\n| \n| 6. In the past 7 days, how many days did you use any illegal or street\n| drugs or abuse any prescription medications?\n| SSN: <.Patient_SSN.>\n| <*Answer_9138*>\n| \n| 7. In the past 7 days, how many days did you use any of the following \n| drugs:\n| \n| 7A. Marijuana (cannabis, pot, weed)?\n| <*Answer_9139*>\n| 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan,\n| Ambien, barbs, Phenobarbital, downers, etc.)?\n| <*Answer_9140*>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| 7C. Cocaine and/or Crack?\n| <*Answer_9141*>\n| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine,\n| Ritalin, Adderall, speed, crystal meth, ice, etc.)?\n| <*Answer_9142*>\n| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy,\n| codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?\n| <*Answer_9143*>\n| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, \n| etc.)?\n
\n\n"], ["32", "AUDIT\n", "\n.|.|Alcohol Use Disorders Identification Test||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nverified for accuracy and used in conjunction with other diagnostic activities.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| AUDIT Score: <-AUDIT->| |\n Questions and Answers||1. How often do you have a drink containing alcohol? | <*Answer_89*>|2. How many drinks containing alcohol do you have on a typical day when you are drinking? \n| <*Answer_90*>|3. How often do you have six or more drinks on one occasion? | <*Answer_91*>|4. How often during the last year have you found that you were not able to stop drinking once you \nhad started? | <*Answer_92*>|5. How often during the last year have you failed to do what was normally expected from you because of drinking? | <*Answer_93*>|6. How often during the last year \nhave you needed a first drink in the morning to get yourself going after a heavy drinking session? | <*Answer_94*>|7. How often during the last year have you had a feeling of guilt or remorse \nafter drinking? | <*Answer_95*>|8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? | <*Answer_96*>|9. Have you or \nsomeone else been injured as a result of your drinking? | <*Answer_97*>|10. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you \ncut down? | <*Answer_98*>| ||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 \n
\n\n"], ["320", "CMAI\n", "\n|COHEN-MANSFIELD AGITATION INVENTORY (CMAI)\n| Gender: <.Patient_Gender.>\n| \n| Aggressive Behavior = <-AGGRESSIVE->\n| Physically Non-Aggressive = <-NON-AGGRESSIVE->\n| Verbally Agitated = <-AGITATED->\n| Other Behavior = <-OTHER->\n| CMAI Total Score = <-TOTAL->\n| \n| Scores can range from 0-25, with higher scores indicating worse \n| symptomatology. \n| \n| \n| A total score of 12 or above suggests the patient \n| might benefit from further assessment and treatment by a mental \n| health clinician aimed at addressing their anger difficulties.\n| \n|Questions and Answers:\n| \n| 1. Cursing or verbal aggression\n| <*Answer_9158*>\n| 2. Hitting, kicking, pushing, biting, scratching, aggressive \n| Date Given: <.Date_Given.>\n| spitting\n| <*Answer_9159*>\n| 3. Grabbing onto people, throwing, tearing, or destroying \n| things\n| <*Answer_9160*>\n| 4. Other aggressive behaviors, including: intentional falling,\n| making verbal/physical sexual advances, eating/drinking/chewing\n| inappropriate substances, hurt self or other\n| <*Answer_9161*>\n| 5. Pace, aimless wandering, trying to get to a different place\n| Clinician: <.Staff_Ordered_By.>\n| (e.g. out of the room, building)\n| <*Answer_9162*>\n| 6. General restlessness, repetitious mannerisms, tapping,\n| strange movements\n| <*Answer_9163*>\n| 7. Inappropriate dress or disrobing\n| <*Answer_9164*>\n| 8. Handling things inappropriately\n| <*Answer_9165*>\n| 9. Constant request for attention or help\n| Location: <.Location.>\n| <*Answer_9166*>\n| 10. Repetitive sentences, calls, questions, or words\n| <*Answer_9167*>\n| 11. Complaining, negativism, refusal to follow directions\n| <*Answer_9168*>\n| 12. Strange noises (weird laughter or crying)\n| <*Answer_9169*>\n| 13. Hiding or hoarding things\n| <*Answer_9170*>\n| 14. Screaming\n| \n| <*Answer_9171*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n|\n| Cohen Mansfield, 1986. All rights reserved.\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["321", "PSEQ-2\n", "\n|Pain Self-Efficacy Questionnaire-2 (PSEQ-2)\n| Gender: <.Patient_Gender.>\n| \n| PSEQ-2 Total Score = <*Answer_7771*>\n|\n| Scores can range from 0-12 with higher scores indicating greater \n| self-efficiency for managing pain.\n| \n| \n|Questions and Answers:\n| \n| \n| 1. I can do some form of work, despite the pain ('work' includes \n| housework, paid and unpaid work).\n| <*Answer_9174*>\n| 2. I can live a normal lifestyle, despite the pain.\n| <*Answer_9175*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n\n\n"], ["322", "NPI-Q\n", "\n|Neuropsychiatric Inventory - Questionnaire (NPI-Q)\n| Gender: <.Patient_Gender.>\n| \n|\n<*Answer_7771*> \n|\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| \n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["324", "G-SAS\n", "\n|Gambling Symptom Assessment Scale (G-SAS)\n| Gender: <.Patient_Gender.>\n| \n| G-SAS Total Score = <-Score->\n| Total score ranges from 0 - 48.\n| 41 - 48 = extreme gambling symptom severity\n| 31 - 40 = severe \n| 21 - 30 = moderate\n| 8 - 20 = mild\n|\n|Questions and Answers:\n| \n| \n| 1. If you had unwanted urges to gamble during the past WEEK, on average,\n| how strong were your urges? Please select the most appropriate number.\n| <*Answer_9214*>\n| 2. During the past WEEK, how many times did you experience urges to \n| gamble? Please select the most appropriate number.\n| <*Answer_9215*>\n| 3. During the past WEEK, how many hours (add up hours) were you \n| preoccupied with your urges to gamble? Please select the most \n| appropriate number.\n| Date Given: <.Date_Given.>\n| <*Answer_9216*>\n| 4. During the past WEEK, how much were you able to control your urges? \n| Please select the most appropriate number.\n| <*Answer_9217*>\n| 5. During the past WEEK, how often did thoughts about gambling and placing\n| bets come up? Please select the most appropriate answer.\n| <*Answer_9218*>\n| 6. During the past WEEK, approximately how many hours (add up hours) did \n| you spend thinking about gambling and thinking about placing bets? \n| Please select the most appropriate number.\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9219*>\n| 7. During the past WEEK, how much were you able to control your thoughts\n| of gambling? Please select the most appropriate number.\n| <*Answer_9220*>\n| 8. During the past WEEK, approximately how much total time did you spend\n| gambling or on gambling related activities. Please select the most\n| appropriate number.\n| <*Answer_9221*>\n| 9. During the past WEEK, on average, how much anticipatory tension and/or\n| excitement did you have shortly before you engaged in gambling? If you \n| Location: <.Location.>\n| did not actually gamble, please estimate how much tension and/or\n| excitement you believe you would have experienced if you had gambled.\n| Please select the most appropriate number.\n| <*Answer_9222*>\n| 10. During the past WEEK, on average, how much excitement and pleasure did \n| you feel when you won on your bet. If you did not actually win at \n| gambling, please estimate how much excitement and pleasure you would \n| have experienced if you had won. Please select the most appropriate \n| number.\n| <*Answer_9223*>\n| \n| 11. During the past WEEK, how much emotional distress (mental pain or \n| anguish, shame, guilt, embarrassment) has your gambling caused you? \n| Please select the most appropriate number.\n| <*Answer_9224*>\n| 12. During the past WEEK, how much personal trouble (relationship, \n| financial, legal, job, medical or health) has your gambling caused you?\n| Please select the most appropriate number.\n| <*Answer_9225*>\n| \n|Information contained in this note is based on a self-report assessment \n| Veteran: <.Patient_Name_Last_First.>\n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["325", "BBGS\n", "\n|Brief Biosocial Gambling Screen (BBGS)\n| Gender: <.Patient_Gender.>\n| \n| BBGS Screen: <*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| 1. During the past 12 months, have you become restless irritable\n| or anxious when trying to stop/cut down on gambling?\n| <*Answer_9226*>\n| \n| 2. During the past 12 months, have you tried to keep your family\n| or friends from knowing how much you gambled?\n| <*Answer_9227*>\n| 3. During the past 12 months did you have such financial trouble\n| as a result of your gambling that you had to get help with\n| living expenses from family, friends or welfare?\n| <*Answer_9228*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n| Date Given: <.Date_Given.>\n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["326", "SDSQ\n", "\n|Single Drug Screening Question (SDSQ)\n| Gender: <.Patient_Gender.>\n| \n| SDSQ Result = <*Answer_7771*>\n| \n| The response to this 1-item screener is "yes" or "no". If the answer is\n| yes, result will be positive. If the answer is no, the result will be \n| negative. \n| \n|Questions and Answers:\n| \n| \n| 1. In the last twelve months, did you use pot (cannabis), use another \n| street drug, or use a prescription medication 'recreationally' (just \n| for the feeling, or using more than prescribed)?\n| <*Answer_9229*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["328", "PCL-5 DAILY\n", "\n|PCL-5 DAILY (PCL-5 DAILY)\n| Gender: <.Patient_Gender.>\n| \n| PCL-5 DAILY Total Score = <-PCL-5 DAILY->\n|\n| This measure assesses an individual's perception of the distress \n| associated with possible PTSD symptoms. It is not used to diagnose \n| PTSD. Symptoms are rated from 0-4 in terms of distress they cause \n| the individual. Scores that are greater than or equal to 31-33 \n| suggest that the veteran may meet the criteria for a PTSD diagnosis.\n| However, it is important to use caution when using this cutoff since \n| \n| it is possible for some Veterans with scores lower than 31-33 to meet \n| criteria for PTSD. Additional testing using a structured diagnostic \n| interview, such as the Clinician Administered PTSD Scale for DSM-5, \n| is recommended to confirm diagnostic status.\n|\n| Values range from 0 to 80 with higher scores indicating more probable \n| PTSD.\n| \n|Questions and Answers:\n| \n| Date Given: <.Date_Given.>\n| 1. Repeated, disturbing, and unwanted memories of the stressful \n| experience?\n| <*Answer_9230*>\n| 2. Repeated, disturbing dreams of the stressful experience?\n| <*Answer_9231*>\n| 3. Suddenly feeling or acting as if the stressful experience were \n| actually happening again (as if you were actually back there \n| reliving it)?\n| <*Answer_9232*>\n| 4. Feeling very upset when something reminded you of the stressful\n| Clinician: <.Staff_Ordered_By.>\n| experience?\n| <*Answer_9233*>\n| 5. Having strong physical reactions when something reminded you of the\n| stressful experience (for example, heart pounding, trouble breathing,\n| sweating)?\n| <*Answer_9234*>\n| 6. Avoiding memories, thoughts, or feelings related to the stressful\n| experience?\n| <*Answer_9235*>\n| 7. Avoiding external reminders of the stressful experience (for example,\n| Location: <.Location.>\n| people, places, conversations, activities, objects, or situations)?\n| <*Answer_9236*>\n| 8. Trouble remembering important parts of the stressful experience?\n| <*Answer_9237*>\n| 9. Having strong negative beliefs about yourself, other people, or the\n| world (for example, having thoughts such as: I am bad, there is\n| something seriously wrong with me, no one can be trusted, the world\n| is completely dangerous)?\n| <*Answer_9238*>\n| 10. Blaming yourself or someone else for the stressful experience or what\n| \n| happened after it?\n| <*Answer_9239*>\n| 11. Having strong negative feelings such as fear, horror, anger, guilt, or\n| shame?\n| <*Answer_9240*>\n| 12. Loss of interest in activities that you used to enjoy?\n| <*Answer_9241*>\n| 13. Feeling distant or cut off from other people?\n| <*Answer_9242*>\n| 14. Trouble experiencing positive feelings (for example, being unable to \n| Veteran: <.Patient_Name_Last_First.>\n| feel happiness or have loving feelings for people close to you)?\n| <*Answer_9243*>\n| 15. Irritable behavior, angry outbursts, or acting aggressively?\n| <*Answer_9244*>\n| 16. Taking too many risks or doing things that could cause you harm?\n| <*Answer_9245*>\n| 17. Being "super alert" or watchful or on guard?\n| <*Answer_9246*>\n| 18. Feeling jumpy or easily startled?\n| <*Answer_9247*>\n| SSN: <.Patient_SSN.>\n| 19. Having difficulty concentrating?\n| <*Answer_9248*>\n| 20. Trouble falling or staying asleep?\n| <*Answer_9249*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["329", "WBS_V2\n", "\n|Well-Being Signs Version 2 (WBS_V2)\n| Gender: <.Patient_Gender.>\n| \n| WBS_V2 Average Score = <*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| Over the past month, on average how often have you been:\n| Use the following scale:\n| 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10\n| \n| None of the Time All of the Time\n|\n|\n| 1. Fully satisfied with how these things are going?\n| <*Answer_9250*>\n| 2. Regularly involved in things that are important to you?\n| <*Answer_9251*>\n| 3. Functioning your best in the most important things you do?\n| <*Answer_9252*>\n| \n| Date Given: <.Date_Given.>\n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["33", "TIDES\n", "\n.|.|TIDES Care Initial Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \npresent:| <*Answer_4198*>|13. Risk Assessment/Management comments:| <*Answer_4199*>|14. Diagnosis of depression in past?| <*Answer_4200*>|15. Prior treatment for depression:| \n<*Answer_4201*>|16. Previous trials of antidepressants:| <*Answer_4202*>|17. Previous periods of psychotherapy:| <*Answer_4203*>|18. Dysthymia symptoms: (In the past two years, have you felt \ndepressed or sad most days, even if you felt okay sometimes?)| <*Answer_4204*>|18.1 Which symptoms have you had?| <*Answer_5101*>|19. Functioning during the past two years:| \n<*Answer_4205*>|20. Comments on history of depression:| <*Answer_4206*>|21. Patient currently on antidepressant?| <*Answer_4207*>|22. Patient taking antidepressant as directed?| \n<*Answer_4208*>|23. Last filled Rx:| <*Answer_4209*>|24. Any side-effects from antidepressant?| <*Answer_4210*>|25. Intensity of side-effects:| <*Answer_4211*>|26. Side-effect(s) from \nantidepressant (Check all that apply):| <*Answer_4212*>|27. Comments on medication compliance and side-effects| <*Answer_4213*>|28. Describe sleep:| <*Answer_4214*>|29. Hours of sleep:| \n<*Answer_4215*>|30. Describe appetite:| <*Answer_4216*>|31. Weight change:| <*Answer_4217*>|32. Symptoms in last month (Which of these symptoms has bothered you in the last month?)| \n<*Answer_4218*>|33. Comments on symptoms:| <*Answer_4219*>|34. Medical co-morbidities (Check all that apply):| <*Answer_4220*>|35. Impact on physical health:| <*Answer_4221*>|36. New \nmedications in last two months (Check all that apply):| <*Answer_4222*>|37. Other medications herbs, or drugs (Check all that apply):| <*Answer_4223*>|38. Recent loss of family or friend?| \n<*Answer_4224*>|39. History of alcohol abuse?| <*Answer_4225*>|40. Has patient used alcohol in past year?| <*Answer_4226*>|41. Frequency of alcohol use:| <*Answer_4227*>|42. Drinks per day:| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Today's date:| <*Answer_4534*>|1. PHQ-9: Declined or could not do.| <*Answer_4187*>|2. Initial PHQ-9 score:| \n <*Answer_4228*>|43. Number of days in a month when patient has five or more drinks:| <*Answer_4230*>|44. Does patient want alcohol treatment?| <*Answer_4229*>|45. Does patient have alcohol \nabuse in Problem List?| <*Answer_4231*>|46. Patient reports significant drug abuse?| <*Answer_4232*>|47. Does patient have drug abuse in Problem List?| <*Answer_4233*>|48. In past month, has \npatient felt anxious, frightened or had panic attack(s)?| <*Answer_4234*>|49. Does the patient want a referral for anxiety/panic symptoms?| <*Answer_4235*>|50. Anxiety/panic in Problem List?| \n <*Answer_4236*>|51. PTSD factors (Check all that apply):| <*Answer_4287*>|52. Diagnosed with PTSD?| <*Answer_5102*>|53. PTSD in active Problem list?| <*Answer_5103*>|54. Referral for PTSD \ntreatment:| <*Answer_4238*>|55. Bipolar diagnosis (Check all that apply):| <*Answer_4239*>|56. Presence of hallucinations or delusions?| <*Answer_4240*>|57. Comments regarding co-morbidity:| \n <*Answer_4241*>|58. Empolyment:| <*Answer_4242*>|59. Is patient involved in volunteer work?| <*Answer_4243*>|60. Does patient have hobbies or activities?| <*Answer_4244*>|61. Marital \nstatus:| <*Answer_4245*>|62. Living situation:| <*Answer_4246*>|63. Patient is able to care for self:| <*Answer_4247*>|64. Children (Check all that apply):| <*Answer_4248*>|65. \nSocial/Family support:| <*Answer_4249*>|66. Support system:| <*Answer_4250*>|67. Is there a specific support person?| <*Answer_4251*>|68. Supportive persons (relationship, not names):| \n<*Answer_4281*>|69. Patient stressors (Check all that apply):| <*Answer_4252*>|70. Comments on functioning/support/stressors| <*Answer_4253*>|71. Service era (Check all that apply):| \n<*Answer_4285*>|72. Was the patient asked about his/her concerns or questions?| <*Answer_5104*>|73. Patient's questions and concerns:| <*Answer_4255*>|74. Patient's treatment preferences:| \n<*Answer_4188*>|3.1 Little interest or pleasure:| <*Answer_4535*>|3.2. Feeling down, depressed or hopeless:| <*Answer_4536*>|3.3. Trouble falling or staying asleep; or sleeping too much| \n<*Answer_4256*>|75. Probable depression diagnosis:| <*Answer_4257*>|76. Co-occurring conditions (Check all that apply):| <*Answer_4288*>|77. Indications for using antidepressants (Check all \nthat apply):| <*Answer_4260*>|78. Indications for referral for psychotherapy (Check all that apply):| <*Answer_4261*>|79. Mental Health Specialty Referral:| <*Answer_4262*>|80. Care Plan \nsuggestions (Check all that apply):| <*Answer_4263*>|81. Suggested Labs (Check all that apply):| <*Answer_4289*>|82. Comments for Primary Care summary:| <*Answer_4264*>|83. Plan for Care \nManager (Check all that apply):| <*Answer_4265*>|84. Comments on Care Manager Plan:| <*Answer_4266*>|85. Previously sent material:| <*Answer_4267*>|86. Self-help plan in place?| \n<*Answer_4268*>|87. Is patient doing self-help activities?| <*Answer_4269*>|88. Information offered and encouragement (Check all that apply):| <*Answer_4270*>|89. Information to be mailed \n(Check all that apply):| <*Answer_4271*>|90. Possible barriers to learning (Check all that apply):| <*Answer_4272*>|91. Patient's preferred learning methods (Check all that apply):| \n<*Answer_4273*>|92. Comments on self-care management and education:| <*Answer_4274*>|93. Best time to call:| <*Answer_4275*>|94. Best days to call:| <*Answer_4276*>|95. Best numbers to \ncall:| <*Answer_4277*>|96. Patient refuses further calls?| <*Answer_4278*>|97. Provider feedback to:| <*Answer_4286*>|98. Call history:| <*Answer_4280*>| $~\n<*Answer_4537*>|3.3.1 Sleep disturbance:| <*Answer_4282*>|3.4. Feeling tired or having little energy:| <*Answer_4538*>|3.5. Poor appetite or overeating:| <*Answer_4539*>|3.5.1 Appetite \ndisturbance:| <*Answer_4283*>|3.6. Feeling bad about yourself:| <*Answer_4540*>|3.7. Trouble concentating on things:| <*Answer_4541*>|3.8. Moving or speaking slowly; or being fidgety or \nrestless:| <*Answer_4542*>|3.8.1 Psycho-motor disturbance:| <*Answer_4284*>|3.9. Thoughts that you would be better off dead or of hurting yourself in some way:| <*Answer_4552*>|4. Number of \nsymptoms present:| <*Answer_4190*>|5. Major Depression Disorder trigger symptoms:| <*Answer_4191*>|6. Initial Symptom Difficulty: Symptoms make work/home/getting along difficult?| \n<*Answer_4192*>|7. Comments on depression screening:| <*Answer_4194*>|8. Suicidial ideation (Check all that apply):| <*Answer_4195*>|9. Other risk factors for suicide (Check all that apply):| \n <*Answer_4196*>|10. Is the VA Medical Center suicide policy initiated?| <*Answer_4197*>|11. Suicidal ideation management (Check all that apply):| <*Answer_4193*>|12. Homicidal ideation \n
\n\n"], ["331", "SODU\n", "\n|Screen of Drug Use (SODU)\n| Gender: <.Patient_Gender.>\n| \n| SODU Result: <*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| 1. How many days in the past 12 months have you used drugs other \n| than alcohol?\n| <*Answer_9255*>\n| \n| 2. How many days in the past 12 months have you used drugs more \n| than you meant to?\n| <*Answer_9256*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["333", "CDSS\n", "\n \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>\n| \n| CDSS Total Score = <-CDSS->\n|\n| A score higher than 6 has an 82% specificity and 85% sensitivity\n| for predicting the presence of a major depressive episode. \n| \n|Questions and Answers:\n| \n|Calgary Depression Scale for Schizophrenia (CDSS)\n| I. DEPRESSION: How would you describe your mood over the last two \n| weeks? Do you remain reasonably cheerful or have you been very \n| depressed or low-spirited recently? In the last two weeks, how \n| often have you (own words) every day? All day?\n| <*Answer_9257*>\n| II. HOPELESSNESS: How do you see the future for yourself? Can you \n| see any future? Or has life seemed quite hopeless? Have you \n| given up or does there still seem some reason for trying?\n| <*Answer_9258*>\n| III. SELF-DEPRECIATION: What is your opinion of yourself compared\n| \n| to other people? Do you feel better, not as good, or about the \n| same as others? Do you feel inferior or even worthless?\n| <*Answer_9259*>\n| IV. GUILTY IDEAS OF REFERENCE: Do you have the feeling that you are \n| being blamed for something or even wrongly accused? What about? \n| (Do not include justifiable blame or accusation. Exclude delusions \n| of guilt.) \n| <*Answer_9260*>\n| V. PATHOLOGICAL GUILT: Do you tend to blame yourself for little \n| things you may have done in the past? Do you think that you \n| Date Given: <.Date_Given.>\n| deserve to be so concerned about this?\n| <*Answer_9261*>\n| VI. MORNING DEPRESSION: When you have felt depressed over the last \n| two weeks, have you noticed the depression being worse at any \n| particular time of day?\n| <*Answer_9262*>\n| VII. EARLY WAKENING: Do you wake earlier in the morning than is normal \n| for you? How many times a week does this happen?\n| <*Answer_9263*>\n| VIII. SUICIDE: Have you felt that life wasn't worth living? Did you \n| Clinician: <.Staff_Ordered_By.>\n| ever feel like ending it all? What did you think you might do? \n| Did you actually try?\n| <*Answer_9264*>\n| IX. OBSERVED DEPRESSION: Based on interviewer's observations during \n| the entire interview. The question "Do you feel like crying?", \n| used at appropriate points in the interview, may elicit information\n| useful to this observation.\n| <*Answer_9265*>\n| \n|Information contained in this note is based on a self-report assessment \n| Location: <.Location.>\n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n
\n\n"], ["334", "LEC\n", "\n|Life Events Checklist for DSM-5 (LEC)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>|| Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | |These are the results grouped by response category. Only items with one of|these responses will be displayed here: Experienced, Witnessed, Learned|about, Job related. Because items can have more than one response, the items|may be displayed in multiple response categories.<*Answer_7771*>| | |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.\n
\n\n"], ["336", "MIOS+B-IPF_V2\n", "\n|\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| Gender: <.Patient_Gender.>\n| \n|<*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| 1. This questionnaire asks about experiences you may have had after a\n|very stressful experience. Please indicate whether you had at least one \n|Moral Injury Outcome Scale and Brief Inventory of Psychological Functioning (MIOS+B-IPF_V2)\n|experience as described below that is currently distressing \n|(select all that apply).\n|\n|<*Answer_7772*>\n|\n| MIOS\n| 2. I blame myself.\n| <*Answer_9284*>\n| 3. I have lost faith in humanity.\n| <*Answer_9285*>\n|\n| 4. People would hate me if they really knew me.\n| <*Answer_9286*>\n| 5. I have trouble seeing goodness in others.\n| <*Answer_9287*>\n| 6. People don't deserve second chances.\n| <*Answer_9288*>\n| 7. I am disgusted by what happened.\n| <*Answer_9289*>\n| 8. I feel like I don't deserve a good life.\n| <*Answer_9290*>\n| Date Given: <.Date_Given.>\n| 9. I keep myself from having success.\n| <*Answer_9291*>\n| 10. I no longer believe there is a higher power.\n| <*Answer_9292*>\n| 11. I lost trust in others.\n| <*Answer_9293*>\n| 12. I am angry all the time.\n| <*Answer_9294*>\n| 13. I am not the good person I thought I was.\n| <*Answer_9295*>\n| Clinician: <.Staff_Ordered_By.>\n| 14. I have lost pride in myself.\n| <*Answer_9296*>\n| 15. I cannot be honest with other people.\n| <*Answer_9297*>\n| B-IPF\n| 16. For the following questions of the B-IPF assessment, reflect on\n| how much this experience made it hard for you to function \n| in each of the areas listed.\n| <*Answer_9298*>\n| 17. I had trouble in my romantic relationship with my spouse or\n| Location: <.Location.>\n| partner.\n| <*Answer_9299*>\n| 18. I had trouble in my relationship with my children.\n| <*Answer_9300*>\n| 19. I had trouble with my family relationships.\n| <*Answer_9301*>\n| 20. I had trouble with my friendships and socializing.\n| <*Answer_9302*>\n| 21. I had trouble at work.\n| <*Answer_9303*>\n| \n| 22. I had trouble with my training and education.\n| <*Answer_9304*>\n| 23. I had trouble with day to day activities, such as doing household\n| chores, running errands and managing my medical care.\n| <*Answer_9305*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n
\n\n"], ["337", "SIP-AD-START_V2\n", "\n|SHORT INVENTORY OF PROBLEMS - AD - Version 2 (SIP-AD-START_V2)\n| Gender: <.Patient_Gender.>\n| I have lost interest in activities and hobbies because of \n| my drinking or drug use.\n| 12a. Ever:\n| <*Answer_9388*>\n| 12b. In the past 30 days:\n| <*Answer_9389*>\n| \n| My drinking or drug use has gotten in the way of my growth \n| as a person.\n| 13a. Ever:\n| \n| <*Answer_9390*>\n| 13b. In the past 30 days:\n| <*Answer_9391*>\n|\n| My drinking or drug use has damaged my social life, \n| popularity, or reputation.\n| 14a. Ever:\n| <*Answer_9392*>\n| 14b. In the past 30 days:\n| <*Answer_9393*>\n| SIP-AD LIFETIME TOTAL SCORE = <-LIFETIME SCORE->\n|\n| I have spent too much or lost a lot of money because of \n| my drinking or drug us\n| 15a. Ever:\n| <*Answer_9394*>\n| 15b. In the past 30 days:\n| <*Answer_9395*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|\n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Lifetime Total scores range from 0-15. Higher scores indicate more\n| negative consequences associated with drinking or drug use across\n| the lifetime.\n|\n| SIP-AD PAST 30-DAY TOTAL SCORE = <-PAST 30-DAY TOTAL SCORE->\n|\n| \n| Past 30-day total scores range from 0-45. Higher scores indicate more \n| negative consequences associated with drinking or drug use within the \n| past 30 days.\n| \n| \n| Questions and Answers:\n|\n| I have been unhappy because of my drinking or drug use.\n| 1a. Ever:\n| <*Answer_9366*>\n| Date Given: <.Date_Given.>\n| 1b. In the past 30 days:\n| <*Answer_9367*>\n|\n| Because of my drinking or drug use, I have lost weight or not eaten \n| properly.\n| 2a. Ever:\n| <*Answer_9368*>\n| 2b. In the past 30 days:\n| <*Answer_9369*>\n|\n| Clinician: <.Staff_Ordered_By.>\n| I have failed to do what is expected of me because of my drinking or \n| drug use.\n| 3a. Ever:\n| <*Answer_9370*>\n| 3b. In the past 30 days:\n| <*Answer_9371*>\n|\n| When drinking or using drugs, my personality has changed for the \n| worse.\n| 4a. Ever:\n| Location: <.Location.>\n| <*Answer_9372*>\n| 4b. In the past 30 days:\n| <*Answer_9373*>\n| \n| I have taken foolish risks when I have been drinking or using drugs.\n| 5a. Ever:\n| <*Answer_9374*>\n| 5b. In the past 30 days:\n| <*Answer_9375*>\n|\n| \n| While drinking or using drugs, I have said harsh or cruel things \n| to someone.\n| 6a. Ever:\n| <*Answer_9376*>\n| 6b. In the past 30 days:\n| <*Answer_9377*>\n|\n| When drinking or using drugs, I have done impulsive things that\n| I regretted later.\n| 7a. Ever:\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_9378*>\n| 7b. In the past 30 days:\n| <*Answer_9379*>\n|\n| I have had money problems because of my drinking or drug use.\n| 8a. Ever:\n| <*Answer_9380*>\n| 8b. In the past 30 days:\n| <*Answer_9381*>\n|\n| SSN: <.Patient_SSN.>\n| My physical appearance has been harmed by my drinking or drug\n| use.\n| 9a. Ever:\n| <*Answer_9382*>\n| 9b. In the past 30 days:\n| <*Answer_9383*>\n|\n| My family has been hurt by my drinking or drug use.\n| 10a. Ever:\n| <*Answer_9384*>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| 10b. In the past 30 days:\n| <*Answer_9385*>\n|\n| A friendship or close relationship has been damaged by my \n| drinking or drug use.\n| 11a. Ever:\n| <*Answer_9386*>\n| 11b. In the past 30 days:\n| <*Answer_9387*>\n|\n
\n\n"], ["338", "WURS-25\n", "\n|Wender Utah Rating Scale-25 (WURS-25)\n| Gender: <.Patient_Gender.>\n| \n| WURS-25 Total Score = <-Total->\n| \n| WURS-25 scores range from 0-100\n|\n| Responses above the cutoff score of 46 (sensitivity &\n| specificity = 96%; Ward et al., 1993) are consistent \n| with an ADHD diagnosis.\n| \n| \n|Questions and Answers:\n| \n| 1. concentration problems, easily distracted \n| <*Answer_9306*>\n| 2. anxious, worrying\n| <*Answer_9307*>\n| 3. nervous, fidgety\n| <*Answer_9308*>\n| 4. inattentive, daydreaming\n| <*Answer_9309*>\n| Date Given: <.Date_Given.>\n| 5. hot- or short-tempered, low boiling point\n| <*Answer_9310*>\n| 6. temper outbursts, tantrums\n| <*Answer_9311*>\n| 7. trouble with stick-to-it-tiveness, not following through, \n| failing to finish things started\n| <*Answer_9312*>\n| 8. stubborn, strong-willed \n| <*Answer_9313*>\n| 9. sad or blue, depressed, unhappy\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9314*>\n| 10. disobedient with parents, rebellious, sassy\n| <*Answer_9315*>\n| 11. low opinion of myself\n| <*Answer_9316*>\n| 12. irritable\n| <*Answer_9317*>\n| 13. moody, ups and downs\n| <*Answer_9318*>\n| 14. angry\n| Location: <.Location.>\n| <*Answer_9319*>\n| 15. acting without thinking, impulsive\n| <*Answer_9320*>\n| 16. tendency to be immature\n| <*Answer_9321*>\n| 17. guilty feelings, regretful\n| <*Answer_9322*>\n| 18. losing control of myself\n| <*Answer_9323*>\n| 19. tendency to be or act irrational\n| \n| <*Answer_9324*>\n| 20. unpopular with other children, didn't keep friends for long, \n| didn't get along with other children\n| <*Answer_9325*>\n| 21. trouble seeing things from someone else's point of view\n| <*Answer_9326*>\n| 22. trouble with authorities, trouble with school, visits to \n| principal's office\n| <*Answer_9327*>\n| 23. overall a poor student, slow learner\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_9328*>\n| 24. trouble with mathematics or numbers\n| <*Answer_9329*>\n| 25. not achieving up to potential\n| <*Answer_9330*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["339", "MOCA_8.1\n", "\n|Montreal Cognitive Assessment Version 8.1 (MOCA_8.1)\n| Gender: <.Patient_Gender.>\n| \n| MOCA_8.1 Total Score = <-Total->\n| A score of 26 or greater is considered normal.\n| Memory Index Score = <-MIS-> / 15\n| \n|Questions and Answers:\n| \n| 1. Alternating Trail Making. Correct Pattern:\n| 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any \n| \n| lines that cross. Any error that is not immediately \n| self-corrected is scored incorrect.\n| <*Answer_9407*>\n| 2. Cube-Visuoconstructional Skills. Correct: All must be \n| present: three-dimensional, all lines are drawn, no line \n| is added, lines are relatively parallel and their length \n| is similar.\n| <*Answer_9408*>\n| 3A. Clock face must be a circle with only minor distortion \n| acceptable (e.g., slight imperfection on closing the circle).\n| Date Given: <.Date_Given.>\n| <*Answer_9409*>\n| 3B. All clock numbers must be present with no additional numbers; \n| numbers must be in the correct order and placed in the \n| approximate quadrants on the clock face; Roman numerals are \n| acceptable; numbers can be placed outside the circle contour.\n| <*Answer_9410*>\n| 3C. There must be two hands jointly indicating the correct time; \n| the hour hand must be clearly shorter than the minute hand; \n| hands must be centered within the clock face with their \n| junction close to the clock center.\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9411*>\n| 4A. Lion\n| <*Answer_9412*>\n| 4B. Rhinoceros or rhino\n| <*Answer_9413*>\n| 4C. Camel or dromedary\n| <*Answer_9414*>\n| 5A. Forward Digit Span.\n| <*Answer_9415*>\n| 5B. Backward Digit Span. Correct response for the backwards trial \n| Location: <.Location.>\n| is 7-4-2.\n| <*Answer_9416*>\n| 5C. Vigilance. Correct when there is zero to one errors (an error is \n| a tap on a wrong letter or a failure to tap on letter A).\n| <*Answer_9417*>\n| 5D. Serial 7 subtraction starting at 100. Continue for five responses\n| <*Answer_9418*>\n| 6A. Sentence repetition. I only know that John is the one to help today.\n| <*Answer_9419*>\n| 6B. Sentence repetition. That cat always hid under the couch when dogs \n| \n| were in the room.\n| <*Answer_9420*>\n| 7. Words beginning with the letter F.\n| <*Answer_9421*>\n| 8A. Similarity between TRAIN - BICYCLE.\n| <*Answer_9422*>\n| 8B. Similarity between WATCH - RULER.\n| <*Answer_9423*>\n| 9A. Recall FACE.\n| <*Answer_9424*>\n| Veteran: <.Patient_Name_Last_First.>\n| 9B. Recall VELVET.\n| <*Answer_9425*>\n| 9C. Recall CHURCH\n| <*Answer_9426*>\n| 9D. Recall DAISY.\n| <*Answer_9427*>\n| 9E. Recall RED.\n| <*Answer_9428*>\n| 10A. Today's date.\n| <*Answer_9429*>\n| SSN: <.Patient_SSN.>\n| 10B. Current month\n| <*Answer_9430*>\n| 10C. Current year\n| <*Answer_9431*>\n| 10D. Day of the week\n| <*Answer_9432*>\n| 10E. What place is this?\n| <*Answer_9433*>\n| 10F. What city are we in?\n| <*Answer_9434*>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| 11. Years of formal education:\n| <*Answer_9435*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities and procedures.\n||Copyright (c) Z. Nasreddine MD\n
\n\n"], ["34", "PHQ9\n", "\n.|.|Patient Health Questionnaire - 9 (PHQ-9)||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \ndead or of hurting yourself in some way| <*Answer_3382*>|10. If you checked off any problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home or get \nalong with other people?| <*Answer_4019*>||Information contained in this note is based on a self report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results \nshould be verified for accuracy and used in conjunction with other diagnostic activities.||Copyright 2001 Pfizer Inc.|All rights reserved. Reproduced with permission of Pfizer Inc.|PRIME-MD is a \ntrademark of Pfizer Inc\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| PHQ-9 Depression Scale Score: <-PHQ9->| <*Answer_7771*> | \n|The total score may range from 0 to 27.| Total Score Depression Severity| ----------- -------------------| 1-4 Minimal depression|\n 5-9 Mild depression| 10-14 Moderate depression| 15-19 Moderately severe depression| 20-27 Severe depression| \n|Questions and Answers||Over the last 2 weeks, how often have you been bothered by any of the \nfollowing problems?|1. Little interest or pleasure in doing things| <*Answer_3374*>|2. Feeling down, depressed, or hopeless| <*Answer_3375*>|3. Trouble falling or staying asleep, or sleeping \ntoo much| <*Answer_3376*>|4. Feeling tired or having little energy| <*Answer_3377*>|5. Poor appetite or overeating| <*Answer_3378*>|6. Feeling bad about yourself or that you are a failure or \nhave let yourself or your family down| <*Answer_3379*>|7. Trouble concentrating on things, such as reading the newspaper or watching television| <*Answer_3380*>|8. Moving or speaking so slowly \nthat other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual| <*Answer_3381*>|9. Thoughts that you would be better off \n
\n\n"], ["340", "ASRS\n", "\n|Adult ADHD Self-Report Scale Symptom Checklist (ASRS)\n| Gender: <.Patient_Gender.>\n|other diagnostic activities.\n| \n| ASRS Scores:\n| \n| Part A\n| ------\n| Number of Items Endorsed: <-Total Part A->\n| \n| <*Answer_7771*>\n|\n| \n| Part B\n| ------\n| Notable Responses: <*Answer_7772*>\n|\n| Questions and Answers:\n|\n| 1. How often do you have trouble wrapping up the final details of \n| a project, once the challenging parts have been done?\n| <*Answer_9331*>\n|\n| Date Given: <.Date_Given.>\n| 2. How often do you have difficulty getting things in order when\n| you have to do a task that requires organization?\n| <*Answer_9332*>\n|\n| 3. How often do you have problems remembering appointments or \n| obligations?\n| <*Answer_9333*>\n|\n| 4. When you have a task that requires a lot of thought, how \n| often do you avoid or delay getting started?\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9334*>\n|\n| 5. How often do you fidget or squirm with your hands or feet \n| when you have to sit down for a long time?\n| <*Answer_9335*>\n|\n| 6. How often do you feel overly active and compelled to do things, \n| like you were driven by a motor?\n| <*Answer_9336*>\n|\n| Location: <.Location.>\n| 7. How often do you make careless mistakes when you have to work on \n| a boring or difficult project?\n| <*Answer_9337*>\n|\n| 8. How often do you have difficulty keeping your attention when you \n| are doing boring or repetitive work?\n| <*Answer_9338*>\n|\n| 9. How often do you have difficulty concentrating on what people \n| say to you, even when they are speaking to you directly?\n| \n| <*Answer_9339*>\n|\n| 10. How often do you misplace or have difficulty finding things at \n| home or at work?\n| <*Answer_9340*>\n|\n| 11. How often are you distracted by activity or noise around you?\n| <*Answer_9341*>\n|\n| 12. How often do you leave your seat in meetings or other situations \n| Veteran: <.Patient_Name_Last_First.>\n| in which you are expected to remain seated?\n| <*Answer_9342*>\n|\n| 13. How often do you feel restless or fidgety?\n| <*Answer_9343*>\n|\n| 14. How often do you have difficulty unwinding and relaxing when you \n| have time to yourself?\n| <*Answer_9344*>\n|\n| SSN: <.Patient_SSN.>\n| 15. How often do you find yourself talking too much when you are in \n| social situations?\n| <*Answer_9345*>\n|\n| 16. When you're in a conversation, how often do you find yourself \n| finishing the sentences of the people you are talking to, \n| before they can finish them themselves?\n| <*Answer_9346*>\n|\n| 17. How often do you have difficulty waiting your turn in situations \n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| when turn taking is required?\n| <*Answer_9347*>\n|\n| 18. How often do you interrupt others when they are busy?\n| <*Answer_9348*>\n| \n|\n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n
\n\n"], ["341", "SIP-AD-30_V2\n", "\n|SHORT INVENTORY OF PROBLEMS - AD - Version 2 (SIP-AD-30_V2)\n| Gender: <.Patient_Gender.>\n| \n|\n|SIP-AD-30_V2 Total Score = <-PAST 30 DAY TOTAL SCORE->\n| \n|Past 30-day total scores range from 0-45. Higher scores indicate more\n|negative consequences associated with drinking or drug use within the\n|past 30 days. \n| \n|Questions and Answers:\n| \n| \n| 1. I have been unhappy because of my drinking or drug use.\n| <*Answer_9350*>\n| 2. Because of my drinking or drug use, I have lost weight or not \n| eaten properly.\n| <*Answer_9351*>\n| 3. I have failed to do what is expected of me because of my drinking \n| or drug use.\n| <*Answer_9352*>\n| 4. When drinking or using drugs, my personality has changed for the \n| Date Given: <.Date_Given.>\n| worse.\n| <*Answer_9353*>\n| 5. I have taken foolish risks when I have been drinking or using drugs.\n| <*Answer_9354*>\n| 6. While drinking or using drugs, I have said harsh or cruel things \n| to someone.\n| <*Answer_9355*>\n| 7. When drinking or using drugs, I have done impulsive things that I\n| regretted later.\n| <*Answer_9356*>\n| Clinician: <.Staff_Ordered_By.>\n| 8. I have had money problems because of my drinking or drug use.\n| <*Answer_9357*>\n| 9. My physical appearance has been harmed by my drinking or drug use.\n| <*Answer_9358*>\n| 10. My family has been hurt by my drinking or drug use.\n| <*Answer_9359*>\n| 11. A friendship or close relationship has been damaged by my drinking \n| or drug use.\n| <*Answer_9360*>\n| 12. I have lost interest in activities and hobbies because of my drinking \n| Location: <.Location.>\n| or drug use.\n| <*Answer_9361*>\n| 13. My drinking or drug use has gotten in the way of my growth as a \n| person.\n| <*Answer_9362*>\n| 14. My drinking or drug use has damaged my social life, popularity, or \n| reputation.\n| <*Answer_9363*>\n| 15. I have spent too much or lost a lot of money\n| <*Answer_9364*>\n| \n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["342", "YMRS\n", "\n|YOUNG MANIA RATING SCALE (YMRS)\n| Gender: <.Patient_Gender.>\n| \n| YMRS Total Score = <-YMRS Total->\n| \n| Scores range from 0 to 60. Higher scores indicate more severe mania \n| symptomatology. A score of 25 or higher can be classified as severely \n| ill (PPV = 83.0%; NPV = 66.0%; Lukasiewicz M, et al. 2013)\n| \n|Questions and Answers:\n| \n| \n| 1. ELEVATED MOOD\n| <*Answer_7771*>\n| 2. INCREASED MOTOR ACTIVITY ENERGY\n| <*Answer_7772*>\n| 3. SEXUAL INTEREST\n| <*Answer_7773*>\n| 4. SLEEP\n| <*Answer_7774*>\n| 5. IRRITABILITY\n| <*Answer_7775*>\n| Date Given: <.Date_Given.>\n| 6. SPEECH (Rate and Amount)\n| <*Answer_7776*>\n| 7. LANGUAGE - THOUGHT DISORDER\n| <*Answer_7777*>\n| 8. CONTENT\n| <*Answer_7778*>\n| 9. DISRUPTIVE - AGGRESSIVE BEHAVIOR\n| <*Answer_7779*>\n| 10. APPEARANCE\n| <*Answer_7780*>\n| Clinician: <.Staff_Ordered_By.>\n| 11. INSIGHT\n| <*Answer_7781*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["343", "MOCA_8.2\n", "\n|Montreal Cognitive Assessment Version 8.2 (MOCA_8.2)\n| Gender: <.Patient_Gender.>\n| \n| MOCA_8.2 Total Score = <-Total->\n| A score of 26 or greater is considered normal.\n| Memory Index Score = <-MIS-> / 15\n| \n|Questions and Answers:\n| \n| 1. Alternating Trail Making. Correct Pattern: \n| 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any \n| \n| lines that cross. Any error that is not immediately \n| self-corrected is scored incorrect.\n| <*Answer_9436*>\n| 2. Chair-Visuoconstructional Skills. Correct: All must be \n| present: three-dimensional, all lines are drawn, no line \n| is added, lines are relatively parallel and their length \n| is similar.\n| <*Answer_9437*>\n| 3A. Clock face must be a circle with only minor distortion \n| acceptable (e.g., slight imperfection on closing the circle).\n| Date Given: <.Date_Given.>\n| <*Answer_9438*>\n| 3B. All clock numbers must be present with no additional numbers; \n| numbers must be in the correct order and placed in the \n| approximate quadrants on the clock face; Roman numerals are \n| acceptable; numbers can be placed outside the circle contour.\n| <*Answer_9439*>\n| 3C. There must be two hands jointly indicating the correct time; \n| the hour hand must be clearly shorter than the minute hand; \n| hands must be centered within the clock face with their \n| junction close to the clock center.\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9440*>\n| 4A. Snake or a type of snake like Boa or Cobra\n| <*Answer_9441*>\n| 4B. Elephant\n| <*Answer_9442*>\n| 4C. Crocodile or alligator\n| <*Answer_9443*>\n| 5A. Forward Digit Span.\n| <*Answer_9444*>\n| 5B. Backward Digit Span. Correct response for the backwards trial \n| Location: <.Location.>\n| is 2-4-7.\n| <*Answer_9445*>\n| 5C. Vigilance. Correct when there is zero to one errors (an error is \n| a tap on a wrong letter or a failure to tap on letter A).\n| <*Answer_9446*>\n| 5D. Serial 7 subtraction starting at 70. Continue for five responses.\n| <*Answer_9447*>\n| 6A. Sentence repetition. The robber of the gray car was stopped by \n| the police.\n| <*Answer_9448*>\n| \n| 6B. Sentence repetition. The student went back to school without his \n| books and pencils.\n| <*Answer_9449*>\n| 7. Words beginning with the letter S.\n| <*Answer_9450*>\n| 8A. Similarity between BED - TABLE.\n| <*Answer_9451*>\n| 8B. Similarity between LETTER - TELEPHONE.\n| <*Answer_9452*>\n| 9A. Recall HAND.\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_9453*>\n| 9B. Recall NYLON\n| <*Answer_9454*>\n| 9C. Recall PARK.\n| <*Answer_9455*>\n| 9D. Recall CARROT.\n| <*Answer_9456*>\n| 9E. Recall YELLOW.\n| <*Answer_9457*>\n| 10A. Today's date.\n| SSN: <.Patient_SSN.>\n| <*Answer_9458*>\n| 10B. Current month\n| <*Answer_9459*>\n| 10C. Current year\n| <*Answer_9460*>\n| 10D. Day of the week\n| <*Answer_9461*>\n| 10E. What place is this?\n| <*Answer_9462*>\n| 10F. What city are we in?\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| <*Answer_9463*>\n| 11. Years of formal education:\n| <*Answer_9464*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities and procedures.\n||Copyright (c) Z. Nasreddine MD\n
\n\n"], ["344", "MOCA_8.3\n", "\n|Montreal Cognitive Assessment Version 8.3 (MOCA_8.3)\n| Gender: <.Patient_Gender.>\n| \n| MOCA_8.3 Total Score = <-Total->\n| A score of 26 or greater is considered normal.\n| Memory Index Score = <-MIS-> / 15\n| \n|Questions and Answers:\n| \n| 1. Alternating Trail Making. Correct Pattern:\n| 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that \n| \n| cross. Any error that is not immediately self-corrected is \n| scored incorrect.\n| <*Answer_9465*>\n| 2. Bed-Visuoconstructional Skills. Correct: All must be present: \n| three-dimensional, all lines are drawn, no line is added, lines \n| are relatively parallel and their length is similar.\n| <*Answer_9466*>\n| 3A. Clock face must be a circle with only minor distortion acceptable \n| (e.g., slight imperfection on closing the circle).\n| <*Answer_9467*>\n| Date Given: <.Date_Given.>\n| 3B. All clock numbers must be present with no additional numbers; \n| numbers must be in the correct order and placed in the approximate \n| quadrants on the clock face; Roman numerals are acceptable; numbers \n| can be placed outside the circle contour.\n| <*Answer_9468*>\n| 3C. There must be two hands jointly indicating the correct time; the\n| hour hand must be clearly shorter than the minute hand; hands must\n| be centered within the clock face with their junction close to the \n| clock center.\n| <*Answer_9469*>\n| Clinician: <.Staff_Ordered_By.>\n| 4A. Horse, pony, mare or foal\n| <*Answer_9470*>\n| 4B. Tiger\n| <*Answer_9471*>\n| 4C. Duck\n| <*Answer_9472*>\n| 5A. Forward Digit Span.\n| <*Answer_9473*>\n| 5B. Backward Digit Span. Correct response for the backwards trial is \n| 7-4-2.\n| Location: <.Location.>\n| <*Answer_9474*>\n| 5C. Vigilance. Correct when there is zero to one errors (an error is a \n| tap on a wrong letter or a failure to tap on letter A).\n| <*Answer_9475*>\n| 5D. Serial 7 subtraction starting at 100. Continue for five responses.\n| <*Answer_9476*>\n| 6A. Sentence repetition. I only know that John is the one to help today.\n| <*Answer_9477*>\n| 6B. Sentence repetition. The cat always hid under the couch when the \n| dogs were in the room.\n| \n| <*Answer_9478*>\n| 7. Words beginning with the letter F.\n| <*Answer_9479*>\n| 8A. Similarity between TRAIN - BICYCLE.\n| <*Answer_9480*>\n| 8B. Similarity between WATCH - RULER.\n| <*Answer_9481*>\n| 9A. Recall LEG.\n| <*Answer_9482*>\n| 9B. Recall COTTON.\n| Veteran: <.Patient_Name_Last_First.>\n| <*Answer_9483*>\n| 9C. Recall SCHOOL.\n| <*Answer_9484*>\n| 9D. Recall TOMATO.\n| <*Answer_9485*>\n| 9E. Recall WHITE.\n| <*Answer_9486*>\n| 10A. Today's date.\n| <*Answer_9487*>\n| 10B. Current month\n| SSN: <.Patient_SSN.>\n| <*Answer_9488*>\n| 10C. Current year\n| <*Answer_9489*>\n| 10D. Day of the week\n| <*Answer_9490*>\n| 10E. What place is this?\n| <*Answer_9491*>\n| 10F. What city are we in?\n| <*Answer_9492*>\n| 11. Years of formal education:\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n| <*Answer_9493*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities and procedures.\n||Copyright (c) Z. Nasreddine MD\n
\n\n"], ["345", "MOCA BLIND\n", "\n|Montreal Cognitive Assessment - Blind (MOCA BLIND) (MOCA BLIND)\n| Gender: <.Patient_Gender.>\n| \n| MOCA BLIND Total Score = <-Total->\n| A score of 19 or greater is considered normal.\n| \n|Questions and Answers:\n| \n| 1A. Forward Digit Span.\n| <*Answer_9494*>\n| 1B. Backward Digit Span. Correct response for the backwards trial \n| \n| is 7-4-2.\n| <*Answer_9495*>\n| 1C. Vigilance. Correct when there is zero to one errors (an error \n| is a tap on a wrong letter or a failure to tap on letter A).\n| <*Answer_9496*>\n| 1D. Serial 7 subtraction starting at 100. Continue for five responses\n| <*Answer_9497*>\n| 2A. Sentence repetition. I only know that John is the one to help today.\n| <*Answer_9498*>\n| 2B. Sentence repetition. That cat always hid under the couch when dogs \n| Date Given: <.Date_Given.>\n| were in the room.\n| <*Answer_9499*>\n| 3. Words beginning with the letter F.\n| <*Answer_9500*>\n| 4A. Similarity between TRAIN - BICYCLE.\n| <*Answer_9501*>\n| 4B. Similarity between WATCH - RULER.\n| <*Answer_9502*>\n| 5A. Recall FACE.\n| <*Answer_9503*>\n| Clinician: <.Staff_Ordered_By.>\n| 5B. Recall VELVET.\n| <*Answer_9504*>\n| 5C. Recall CHURCH\n| <*Answer_9505*>\n| 5D. Recall DAISY.\n| <*Answer_9506*>\n| 5E. Recall RED.\n| <*Answer_9507*>\n| 6A. Today's date.\n| <*Answer_9508*>\n| Location: <.Location.>\n| 6B. Current month\n| <*Answer_9509*>\n| 6C. Current year\n| <*Answer_9510*>\n| 6D. Day of the week\n| <*Answer_9511*>\n| 6E. What place is this?\n| <*Answer_9512*>\n| 6F. What city are we in?\n| <*Answer_9513*>\n| \n| 7. Years of formal education:\n| <*Answer_9514*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities and procedures.\n||Copyright (c) Z. Nasreddine MD\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["346", "ALSFRS-R\n", "\n|ALS Functional Rating Scale - Revised (ALSFRS-R)\n| Gender: <.Patient_Gender.>\n| \n| ALSFRS-R Total Score = <-Total->\n| Scores range from 0 to 48, with higher scores indicating that more \n| function is retained.\n| \n|Questions and Answers:\n| \n| 1. Speech\n| <*Answer_9515*>\n| \n| 2. Salivation\n<*Answer_7771*>\n| 3. Swallowing\n| <*Answer_9517*>\n| 4. Handwriting\n| <*Answer_9518*>\n| 5. Does Veteran have a gastrostomy\n| <*Answer_9519*>\n| 5A. Cutting food and handling utensils (patients without gastrostomy)\n| <*Answer_9520*>\n| Date Given: <.Date_Given.>\n| 5B. Cutting food and handling utensils (patients with gastrostomy) \n| <*Answer_9521*>\n| 6. Dressing and hygiene\n<*Answer_7772*>\n| 7. Turning in bed and adjusting bed clothes\n| <*Answer_9523*>\n| 8. Walking\n| <*Answer_9524*>\n| 9. Climbing stairs\n| <*Answer_9525*>\n| Clinician: <.Staff_Ordered_By.>\n| 10. Dyspnea\n<*Answer_7773*>\n| 11. Orthopnea\n<*Answer_7774*>\n| 12. Respiratory insufficiency\n| <*Answer_9528*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n| Location: <.Location.>\n|other diagnostic activities.\n\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["347", "ALSSQOL-SF\n", "\n|ALS-Specific Quality of Life - Short Form (ALSSQOL-SF)\n| Gender: <.Patient_Gender.>\n| \n|<*Answer_7771*>\n| \n| \n|Questions and Answers:\n| \n| Please assess your overall quality of life over the past week\n| (7 days). Considering all parts of my life - physical, emotional,\n| social, spiritual, and financial - over the past week, the quality\n| \n| of my life has been:\n| <*Answer_9556*>\n|\n| 1. I have experienced pain.\n| <*Answer_9529*>\n| 2. I have experienced fatigue.\n| <*Answer_9530*>\n| 3. I have experienced excessive saliva.\n| <*Answer_9531*>\n| 4. I have experienced problems with speaking.\n| Date Given: <.Date_Given.>\n| <*Answer_9532*>\n| 5. I have experienced problems with my strength and ability to move.\n| <*Answer_9533*>\n| 6. I have experienced problems with sleep.\n| <*Answer_9534*>\n| 7. I have felt physically terrible.\n| <*Answer_9535*>\n| 8. The world has been caring and responsive to my needs.\n| <*Answer_9536*>\n| 9. I have felt supported.\n| Clinician: <.Staff_Ordered_By.>\n| <*Answer_9537*>\n| 10. I have been depressed.\n| <*Answer_9538*>\n| 11. Relationships with those closest to me have been satisfying.\n| <*Answer_9539*>\n| 12. My religion has been a source of strength or comfort to me.\n| <*Answer_9540*>\n| 13. I consider myself to have been religious or spiritual.\n| <*Answer_9541*>\n| 14. I have felt hopeless.\n| Location: <.Location.>\n| <*Answer_9542*>\n| 15. I have felt sad.\n| <*Answer_9543*>\n| 16. I have enjoyed the beauty of my surroundings.\n| <*Answer_9544*>\n| 17. My desire for emotional intimacy has been strong.\n| <*Answer_9545*>\n| 18. I have shared emotional intimacy with others.\n| <*Answer_9546*>\n| 19. My desire for physical intimacy has been strong.\n| \n| <*Answer_9547*>\n| 20. I have shared physical intimacy with others.\n| <*Answer_9548*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["348", "AAQ-II-7\n", "\n|Acceptance and Action Questionnaire - 7 Item (AAQ-II-7)\n| Gender: <.Patient_Gender.>\n| \n| AAQ-II-7 Total Score = <-Total->\n| Higher scores equal greater levels of psychological inflexibility.\n| \n|Questions and Answers:\n| \n| 1. My painful experiences and memories make it difficult for me to \n| live a life that I would value.\n| <*Answer_9549*>\n| \n| 2. I'm afraid of my feelings.\n| <*Answer_9550*>\n| 3. I worry about not being able to control my worries and feelings.\n| <*Answer_9551*>\n| 4. My painful memories prevent me from having a fulfilling life.\n| <*Answer_9552*>\n| 5. Emotions cause problems in my life.\n| <*Answer_9553*>\n| 6. It seems like most people are handling their lives better than \n| I am.\n| Date Given: <.Date_Given.>\n| <*Answer_9554*>\n| 7. Worries get in the way of my success.\n| <*Answer_9555*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["349", "MAHC-10\n", "\n|Missouri Alliance for Home Care - 10 questions (MAHC-10)\n| Gender: <.Patient_Gender.>\n| \n| MAHC-10 Total = <-MAHC-10 Total->\n|\n| A score of 4 or more is considered at risk for falling. \n| \n|Questions and Answers:\n| \n| 1. Age 65+\n| <*Answer_9557*>\n| \n| 2. Diagnosis (3 or more co-existing)\n| Includes only documented medical diagnoses\n| <*Answer_9558*>\n| 3. Prior history of falls within 3 months\n| Any unintentional change in position resulting in \n| coming to rest on the ground or at a lower level\n| <*Answer_9559*>\n| 4. Incontinence\n| Inability to make it to the bathroom or commode \n| in timely manner. Includes frequency, urgency, and/or \n| Date Given: <.Date_Given.>\n| nocturia.\n| <*Answer_9560*>\n| 5. Visual Impairment\n| Includes but not limited to, macular degeneration, \n| diabetic retinopathies, visual field loss, age related \n| changes, decline in visual acuity, accommodation, glare \n| tolerance, depth perception, and night vision or not \n| wearing prescribed glasses or having the correct prescription.\n| <*Answer_9561*>\n| 6. Impaired functional mobility\n| Clinician: <.Staff_Ordered_By.>\n| May include patients who need help with IADLS or ADLS or \n| have gait or transfer problems, arthritis, pain, fear of \n| falling, foot problems, impaired sensation, impaired \n| coordination or improper use of assistive devices.\n| <*Answer_9562*>\n| 7. Environmental hazards\n| May include but not limited to, poor illumination, \n| equipment tubing, inappropriate footwear, pets, hard to reach \n| items, floor surfaces that are uneven or cluttered, or \n| outdoor entry and exits.\n| Location: <.Location.>\n| <*Answer_9563*>\n| 8. Poly Pharmacy (4 or more prescriptions - any type)\n| All PRESCRIPTIONS including prescriptions for OTC meds. Drugs \n| highly associated with fall risk include but not limited to, \n| sedatives, anti-depressants, tranquilizers, narcotics, \n| antihypertensives, cardiac meds, corticosteroids, anti-anxiety \n| drugs, anticholinergic drugs, and hypoglycemic drugs. \n| <*Answer_9564*>\n| 9. Pain affecting level of function\n| Pain often affects an individual's desire or ability to move \n| \n| or pain can be a factor in depression or compliance with safety | recommendations.\n| <*Answer_9565*>\n| 10. Cognitive impairment\n| Could include patients with dementia, Alzheimer's or stroke \n| patients or patients who are confused, use poor judgment, \n| have decreased comprehension, impulsivity, memory deficits.\n| Consider patients ability to adhere to the plan of care.\n| <*Answer_9566*>\n| \n|Information contained in this note is based on a self-report assessment \n| Veteran: <.Patient_Name_Last_First.>\n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["35", "ISMI\n", "\n.|.|Internalized Stigma of Mental Illness Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5316*>|9. I don't socialize as much as I used to because my mental illness might make me look or behave "weird."| <*Answer_5317*>|10. People with mental illness cannot live a good, \nrewarding life.| <*Answer_5318*>|11. I don't talk about myself much because I don't want to burden others with my mental illness.| <*Answer_5319*>|12. Negative stereotypes about mental illness \nkeep me isolated from the "normal" world.| <*Answer_5320*>|13. Being around people who don't have a mental illness makes me feel out of place or inadequate.| <*Answer_5321*>|14. I feel \ncomfortable being seen in public with an obviously mentally ill person.| <*Answer_5322*>|15. People often patronize me, or treat me like a child, just because I have a mental illness.| \n<*Answer_5323*>|16. I am disappointed in myself for having a mental illness.| <*Answer_5324*>|17. Having a mental illness has spoiled my life.| <*Answer_5325*>|18. People can tell that I have a \nmental illness by the way I look.| <*Answer_5326*>|19. Because I have a mental illness, I need others to make most decisions for me.| <*Answer_5327*>|20. I stay away from social situations in \norder to protect my family or friends from embarrassment.| <*Answer_5328*>|21. People without mental illness could not possibly understand me.| <*Answer_5329*>|22. People ignore me or take me \nless seriously just because I have a mental illness.| <*Answer_5330*>|23. I can't contribute anything to society because I have a mental illness.| <*Answer_5331*>|24. Living with mental illness \nhas made me a tough survivor.| <*Answer_5332*>|25. Nobody would be interested in getting close to me because I have a mental illness.| <*Answer_5333*>|26. In general, I am able to live my life \nthe way I want to.| <*Answer_5334*>|27. I can have a good, fulfilling life, despite my mental illness.| <*Answer_5335*>|28. Others think that I can't achieve much in life because I have a \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| ISMI Scales| Alienation <-Alienation->| Stereotype Endorsement <-Stereotype Endorsement->| Discrimination Experience <-Discrimination \nmental illness.| <*Answer_5336*>|29. Stereotypes about the mentally ill apply to me.| <*Answer_5337*>|| $~\nExperience->| Social Withdrawal <-Social Withdrawal->| Stigma Resistance <-Stigma Resistance->| Total Score <-Total Score->|| 4-category method (following the method used by \nLysaker et al., 2007)| 1.00-2.00: minimal to no internalized \n stigma| 2.01-2.50: mild internalized stigma| 2.51-3.00: moderate internalized stigma| 3.01-4.00: severe internalized stigma|| 2-category method (following the method used by Ritsher & Phelan, 2004)| 1.00-2.50: does not \nreport high internalized stigma| 2.51-4.00: reports high internalized stigma||Questions and Answers||1. I feel out of place in the world because I have a mental illness.|\n <*Answer_5309*>|2. Mentally ill people tend to be violent.| <*Answer_5310*>|3. People discriminate against me because I have a mental illness.| <*Answer_5311*>|4. I avoid getting close to \npeople who don't have a mental illness to avoid rejection.| <*Answer_5312*>|5. I am embarrassed or ashamed that I have a mental illness.| <*Answer_5313*>|6. Mentally ill people shouldn't get \nmarried.| <*Answer_5314*>|7. People with mental illness make important contributions to society.| <*Answer_5315*>|8. I feel inferior to others who don't have a mental illness.| \n
\n\n"], ["350", "NSI FOR TBI\n", "\n|Neurobehavioral Symptom Inventory for Traumatic Brain Injury (NSI FOR TBI)\n| Gender: <.Patient_Gender.>\n| \n| NSI Subscales\n| Cognitive subscale = <-Cognitive subscale->\n| Mood-Behavioral subscale = <-Mood-Behavioral subscale->\n| Vestibular - Sensory subscale = <-Vestibular - Sensory subscale->\n| \n| \n|Questions and Answers:\n| \n| \n| 1. Feeling dizzy\n| <*Answer_7771*>\n| 2. Loss of balance\n| <*Answer_7772*>\n| 3. Poor coordination, clumsy\n| <*Answer_7773*>\n| 4. Headaches\n| <*Answer_7774*>\n| 5. Nausea\n| <*Answer_7775*>\n| Date Given: <.Date_Given.>\n| 6. Vision problems, blurring, trouble seeing\n| <*Answer_7776*>\n| 7. Sensitivity to light\n| <*Answer_7777*>\n| 8. Hearing difficulty\n| <*Answer_7778*>\n| 9. Sensitivity to noise\n| <*Answer_7779*>\n| 10. Numbness or tingling on parts of my body\n| <*Answer_7780*>\n| Clinician: <.Staff_Ordered_By.>\n| 11. Change in taste and/or smell\n| <*Answer_7781*>\n| 12. Loss of appetite or increased appetite\n| <*Answer_7782*>\n| 13. Poor concentration, can't pay attention, easily distracted\n| <*Answer_7783*>\n| 14. Forgetfulness, can't remember things\n| <*Answer_7784*>\n| 15. Difficulty making decisions\n| <*Answer_7785*>\n| Location: <.Location.>\n| 16. Slowed thinking, difficulty getting organized, can't finish things\n| <*Answer_7786*>\n| 17. Fatigue, loss of energy, getting tired easily\n| <*Answer_7787*>\n| 18. Difficulty falling or staying asleep\n| <*Answer_7788*>\n| 19. Feeling anxious or tense\n| <*Answer_7789*>\n| 20. Feeling depressed or sad\n| <*Answer_7790*>\n| \n| 21. Irritability, easily annoyed\n| <*Answer_7791*>\n| 22. Poor frustration tolerance, feeling easily overwhelmed by things\n| <*Answer_7792*>\n| \n|Information contained in this note is based on a self-report assessment \n|and is not sufficient to use alone for diagnostic purposes. Assessment \n|results should be verified for accuracy and used in conjunction with \n|other diagnostic activities.\n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["36", "CPR 1\n", "\n|Test only||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>| <_Script_3_> <_Script_4_> $~ \n
\n\n"], ["37", "BASIS-24\n", "\n.|.|Behavior and Symptom Identification Scale - 24||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nalong well in social situations?| <*Answer_5362*>|7. Feel close to another person?| <*Answer_5363*>|8. Feel like you had someone to turn to if you needed help?| <*Answer_5364*>|9. Feel \nconfident in yourself?| <*Answer_5365*>|10. Feel sad or depressed?| <*Answer_5366*>|11. Think about ending your life?| <*Answer_5367*>|12. Feel nervous?| <*Answer_5368*>|13. Have thoughts \nracing through your head?| <*Answer_5369*>|14. Think you had special powers?| <*Answer_5370*>|15. Hear voices or see things?| <*Answer_5371*>|16. Think people were watching you?| \n<*Answer_5372*>|17. Think people were against you?| <*Answer_5373*>|18. Have mood swings?| <*Answer_5374*>|19. Feel short-tempered?| <*Answer_5375*>|20. Think about hurting yourself?| \n<*Answer_5376*>|21. Did you have an urge to drink alcohol or take street drugs?| <*Answer_5377*>|22. Did anyone talk to you about your drinking or drug use?| <*Answer_5378*>|23. Did you try to \nhide your drinking or drug use?| <*Answer_5379*>|24. Did you have problems from your drinking or drug use?| <*Answer_5380*>|||Information contained in this note is based on a self-report \nassessment 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 \nprocedures.||Copyright (c) 2003 McLean Hospital| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| BASIS-24 Scales| Depression and Functioning <-Depression and Functioning->| Interpersonal Problems <-Interpersonal Problems->| \n Psychotic Symptoms <-Psychotic Symptoms->| Alcohol\n/Drug Use <-Alcohol/Drug Use->| Emotional Lability\n <-Emotional Lability->| Self-Harm \n<-Self-Harm->| Overall <-Overall->\n|| Note: Lower scores indicate less frequent symptoms or difficulty | whereas higher scores reflect more serious symptoms or difficulty.\n| Range of scores: 0 to 4. ||Questions and Answers||1. Managing your day-to-day life?| <*Answer_5357*>|2. Coping with problems in your\n life?| <*Answer_5358*>|3. Concentrating?| <*Answer_5359*>|4. Get along with people in your family?| <*Answer_5360*>|5. Get along with people outside your family?| <*Answer_5361*>|6. Get \n
\n\n"], ["38", "PCL-SZ\n", "\n.|.|PTSD Checklist Stressor Specific||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5412*>|13. Trouble FALLING or STAYING ASLEEP?| <*Answer_5413*>|14. Feeling IRRITABLE or having ANGRY OUTBURSTS?| <*Answer_5414*>|15. Having DIFFICULTY CONCENTRATING?| \n<*Answer_5415*>|16. Being "SUPERALERT" or watchful or on guard?| <*Answer_5416*>|17. Feeling JUMPY or easily startled?| <*Answer_5417*>|18. How difficult have these problems made it for you to \ndo your work, take care of things at home, or get along with other people?| <*Answer_5418*>|19. During the last two weeks have you had thoughts that you would be better off dead, or of hurting \nyourself in some way?| <*Answer_5419*>| 19A. How often have you had these thoughts?| <*Answer_5420*>|||Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>| |PCL-SZ Score: <-Score->|| Range 0-68. A high score indicates PTSD symptoms are endorsed.||Questions and Answers||A. The \nevent you experienced was:| <*Answer_5399*>|B. When did the event occur:| <*Answer_5433*>||1. Repeated disturbing MEMORIES, THOUGHTS or IMAGES of the stressful experience?| \n<*Answer_5401*>|2. Repeated disturbing DREAMS of the stressful experience?| <*Answer_5402*>|3. Suddenly ACTING or FEELING as if the stressful experience from the past were happening again (as if \nyou were reliving it)?| <*Answer_5403*>|4. Feeling VERY UPSET when SOMETHING reminded you of the stressful experience?| <*Answer_5404*>|5. Having PHYSICAL reactions (e.g. heart pounding, \ntrouble breathing, sweating) when SOMETHING REMINDED you of the stressful experience?| <*Answer_5405*>|6. Avoiding THINKING ABOUT or TALKING ABOUT the stressful experience from the past or \nAVOIDING HAVING FEELINGS related to it?| <*Answer_5406*>|7. Avoiding ACTIVITIES or SITUATIONS because they REMINDED you of the stressful experience?| <*Answer_5407*>|8. Trouble REMEMBERING \nIMPORTANT PARTS of the stressful experience?| <*Answer_5408*>|9. LOSS OF INTEREST in activities that you used to enjoy?| <*Answer_5409*>|10. Feeling DISTANT or CUT OFF from other people?| \n<*Answer_5410*>|11. Feeling EMOTIONALLY NUMB or being unable to have loving feelings for those close to you?| <*Answer_5411*>|12. Feeling as if your FUTURE somehow will be CUT SHORT?| \n
\n\n"], ["39", "COWS\n", "\n.| .| Clinical Opiate Withdrawal Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | COWS Scale: <-COWS Scale->| | 5-12 Mild withdrawal| 13-24 Moderate| 25-36 Moderately \nsevere| 37+ Severe withdrawal| | Questions and Answers| | 1. Resting Pulse Rate: | <*Answer_4022*>| 2. Sweating: | <*Answer_4033*>| 3. Restlessness: | <*Answer_4035*>| 4. \nPupil size:| <*Answer_4036*>| 5. Bone or joint aches:| <*Answer_4037*>| 6. Runny nose or tearing: | <*Answer_4038*>| 7. GI upset: | <*Answer_4039*>| 8. Tremor: | <*Answer_4040*>| \n9. Yawning: | <*Answer_4041*>| 10. Anxiety or Irritability:| <*Answer_4042*>| 11. Gooseflesh skin:| <*Answer_4043*>| | $~\n
\n\n"], ["4", "CDR\n", "\n.|.|Clinical Dementia Rating||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Dementia Rating| CDR: <-CDR->||Questions and Answers||1. Memory| <*Answer_3903*>|2. Orientation| \n<*Answer_3904*>|3. Judgment and Problem Solving| <*Answer_3905*>|4. Community Affairs| <*Answer_3906*>|5. Home and Hobbies| <*Answer_3907*>|6. Personal Care| <*Answer_3908*>|||Information \ncontained 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 \nwith other diagnostic activities and procedures.| $~\n
\n\n"], ["40", "HIH\n", "\n.|.|Health Issue History||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1. Airways and Breathing System| <*Answer_4065*>|2. Allergies and Immune System| <*Answer_4066*>|3. Alchol History| <*Answer_4067*>| $~\n
\n\n"], ["41", "MOVE! 23\n", "\n.|.|MOVE!23||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \nbuy food 'to go' ?| <*Answer_4074*>|16. How much regular soda, sweet tea, juice, or juicy drinks do you drink most days? (Do not include diet or sugar free soda, unsweetened tea, or other sugar \nfree drinks.)| <*Answer_4075*>|17. How many alcoholic drinks do you have in an average week? (One serving is a 12 oz can of beer or malt liquor or a 6 oz glasses of wine or a 1 oz shot of \nhard/distilled liquor.)| <*Answer_4076*>|18. How fast do you usually eat?| <*Answer_4077*>|19. On average, how often have you eaten extremely large amounts of food and felt that your eating was \nout of control at that time?| <*Answer_4078*>|20. Do you use a wheelchair or are largely confined to your bed?| <*Answer_4079*>|21a. Are you limited in any daily activities or work performance \nbecause of your physical health? Climbing a flight of stairs:| <*Answer_4080*>|21b. Are you limited in any daily activities or work performance because of your physical health? Walking several \nblocks:| <*Answer_4081*>|21c. Are you limited in any daily activities or work performance because of your physical health? Lifting or carrying packages or groceries:| <*Answer_4082*>|22. Using \nthe 1-10 scale below, which number best describes your typical daily physical activity/exercise? "1" indicates no activity, "5" indicates 15 minutes every three days, "10" means one hour or more of \ndaily exercise/activity. | <*Answer_4083*>|23. Which statement most closely applies to your attitude about exercise?| <*Answer_4084*>|24. Which statement best indicates how much you agree with, \n"I am satisfied with my current level of fitness."| <*Answer_4085*>|| $~\n(<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||1. Please check any of the following medical conditions or health problems you currently have:| <*Answer_4056*>|2. I consider \nmyself to be:| <*Answer_4057*>|3. Select the answer that best describes your rate of weight gain over the years:| <*Answer_4058*>|4. Select the answer that best describes your family:| \n<*Answer_4059*>|5. Which statement most closely applies to you:| <*Answer_4060*>|6. How much weight do you think you realistically could lose in one year without surgery?| <*Answer_4061*>|7. \nHow confident are you that you can lose weight and keep it off?| <*Answer_4062*>|8. How satisfied are you with the appearance of your body?| <*Answer_4063*>|9. Do any of the following have \nanything to do with your being overweight? Check all that apply to you.| <*Answer_4064*>|10. How much can you rely on family or friends for support and encouragement?| <*Answer_4068*>|11. What \ndo you think may get in the way of changing your eating habits? Check all that apply to you.| <*Answer_4069*>|12. What do you think may get in the way of changing your physical activity habits? \nCheck all that apply to you.| <*Answer_4070*>|13. Are you currently experiencing any of the following? Check all that apply.| <*Answer_4071*>|13a. Are you currently being treated for any of \nthe following? Check all that apply.| <*Answer_4072*>|14. How many times a day do you typically eat, including snacks?| <*Answer_4073*>|15. How many times a week do you usually eat 'out' or \n
\n\n"], ["42", "TBI 2ND LEVEL EVAL\n", "\n|Traumatic Brain Injury: 2nd Level Evaluation||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \ntoxic fumes, or crush injuries from structures falling onto you? | <*Answer_4107*>|5d4a. Distance to blast: (Indicate the closest episode)| <*Answer_4108*>|5d5. Type of blast exposures: (Check \nall that apply)| <*Answer_4109*>|5e. Other causes of injury: (Were you injured during your deployment in any other way?)| <*Answer_4110*>|6. Did you lose consciousness immediately after any of \nthese experiences?| <*Answer_4111*>|6a. What was the longest duration of unconsciousness?| <*Answer_4112*>|7. Did you have a period of disorientation or confusion immediately following the \nincident?| <*Answer_4113*>|7a. What was the duration of longest period of alteration of consciousness?| <*Answer_4114*>|8. Did you experience a period of memory loss immediately before or after \nthe incident?| <*Answer_4115*>|8a. What was the duration of longest period of memory loss?| <*Answer_4116*>|9. During this/these experience(s), did an object penetrate your skull/cranium:| \n<*Answer_4117*>|10. Were you wearing a helmet at the time of most serious injury?| <*Answer_4118*>|11. Were you evacuated from theatre?| <*Answer_4119*>|12. Prior to this evaluation, had you \nreceived any professional treatment (including medications) for your deployment related TBI symptoms?| <*Answer_4120*>|12a. Have you ever been prescribed medications for symptoms related to your \ndeployment related TBI symptoms?| <*Answer_4121*>|13. Prior to your OEF/OIF deployment, did you experience a brain injury or concussion?| <*Answer_4122*>|14. Since your OEF/OIF deployment, have \nyou experienced a brain injury or concussion?| <*Answer_4123*>|15. Since the time of your deployment related injury/injuries, has anyone told you that you were acting differently?| \n<*Answer_4124*>|16a. Feeling Dizzy:| <*Answer_4125*>|16b. Loss of balance:| <*Answer_4126*>|16c. Poor coordination, clumsy:| <*Answer_4127*>|16d. Headaches:| <*Answer_4128*>|16e. Nausea:| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||1. Current marital status:| <*Answer_4091*>|2. Highest level of educational achievement:| <*Answer_4092*>|3. Current \n <*Answer_4129*>|16f. Vision problems, blurring, trouble seeing:| <*Answer_4130*>|16g. Sensitivity to light:| <*Answer_4131*>|16h. Hearing difficulty:| <*Answer_4132*>|16i. Sensitivity to \nnoise:| <*Answer_4133*>|16j. Numbness or tingling in parts of my body:| <*Answer_4134*>|16k. Change in ability to taste and/or smell:| <*Answer_4135*>|16l. Loss of appetite or increase \nappetite:| <*Answer_4136*>|16m. Poor concentration, can't pay attention:| <*Answer_4137*>|16n. Forgetfullness, can't remember things:| <*Answer_4138*>|16o. Difficutly making decisions:| \n<*Answer_4139*>|16p. Slowed thinking, difficulty getting organized, can't finish things:| <*Answer_4140*>|16q. Fatigue, loss of energy, getting tired easily:| <*Answer_4141*>|16r. Difficulty \nfalling or staying asleep:| <*Answer_4142*>|16s. Feeling anxious or tense:| <*Answer_4143*>|16t. Felling depressed or sad:| <*Answer_4144*>|16u. Irritability, easily annoyed:| \n<*Answer_4145*>|16v. Poor frustration tolerance, feeling easily overwhelmed by things:| <*Answer_4146*>|17. Overall, in the last 30 days how much did these difficulties (symptoms?) interfere with \nyour life?| <*Answer_4147*>|17a. In what areas of your life are you having difficulties because of these symptoms?| <*Answer_4148*>|18. In the last 30 days, have you had any problems with \npain?| <*Answer_4149*>|18a. Location of pain: (Check all that apply)| <*Answer_4150*>|18a1. Other:| <*Answer_4151*>|18b. In the last 30 days, how much did pain interfere with your life?| \n<*Answer_4152*>|18c. In what areas of your life are you having difficulties because of pain?| <*Answer_4153*>|19. Since the time of your deployment related injury/injuries, are your overall \nsymptoms:| <*Answer_4154*>|20. Psychiatric Symptoms:| <*Answer_4155*>|20a. Psychiatric disorder:| <*Answer_4156*>|21. SCI:| <*Answer_4157*>|22. Amputation:| <*Answer_4158*>|23. Other \nemployment status:| <*Answer_4093*>|4a. First Date (Oldest injury, MM/DD/YYYY):| <*Answer_4094*>|4b. Second date:| <*Answer_4095*>|4c. Third date:| <*Answer_4096*>|5a. Bullet:| \nsignificant medical conditions/problems:| <*Answer_4159*>|24. Are the findings consistent with diagnosis of TBI ?| <*Answer_4160*>|25. Follow up plan:| <*Answer_4161*>|25a. Education:| \n<*Answer_4162*>|25b. Consult requested with: (Check all that apply)| <*Answer_4163*>|25c. Referral to Polytrauma Network Site (PNS):| <*Answer_4164*>|25d. Electro diagnostic study (nerve \nconduction / electromyogram):| <*Answer_4165*>|25e. Lab:| <*Answer_4166*>|25f. Head CT:| <*Answer_4167*>|25g. Brain MRI:| <*Answer_4168*>|25h. Other Consultation:| <*Answer_4169*>|25i. \nNew medication trial or change in dose of existing medication:| <*Answer_4170*>|25i1. Specify other:| <*Answer_4171*>|26. Other information (use for additional History of Present Illness, \nSocial History, Patient Goals, Details of Plan, etc.):| <*Answer_4172*>| $~\n<*Answer_4097*>|5b. Vehicular:| <*Answer_4098*>|5c. Fall:| <*Answer_4099*>|5d. Blast:| <*Answer_4100*>|5d1. When a high-explosive bomb or IED goes off there is a "blast wave" which is a wave \nof highly compressed gas that may feel almost like being smashed into a wall. Do you remember experiencing this or were told that you experienced it? | <*Answer_4101*>|5d1a. Distance to blast: \n(Indicate the closest episode)| <*Answer_4102*>|5d2. This "blast wave" is followed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough \nto the blast to be "peppered" or hit by such debris,shrapnel, or other items? | <*Answer_4103*>|5d2a. Distance to blast: (Indicate the closest episode)| <*Answer_4104*>|5d3. Were you thrown to \nthe ground or against some stationary object, like a wall or vehicle, by the explosion? This is not asking if you "ducked to the ground" to protect yourself.| <*Answer_4105*>|5d3a. Distance to \nblast: (Indicate the closest episode)| <*Answer_4106*>|5d4. Did you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations, breathing \n
\n\n"], ["43", "BOMC\n", "\n.|.|The Six-Item Blessed Orientation-Memory-Concentration Test (BOMC)||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| BOMC weighted error score: <-Weighted error score-> ||This score has a range of 0 to 28.|A score \ngreater than 10 is considered abnormal and warrants further \nevaluation.||Questions and Answers||\n1. What year is it now?| <*Answer_4173*>|1a.\nPatient's response:| <*Answer_4179*>|2. What month is it now?| <*Answer_4174*>|2a. Patient's response:| <*Answer_4180*>|3. About what time is it? (within one hour)| <*Answer_4175*>|3a. \nPatient's response:| <*Answer_4181*>|4. Count backwards from 20 to 1.| <*Answer_4176*>|4a. Patient's response:| <*Answer_4182*>|5. Say the months in reverse order.| <*Answer_4177*>|5a. \nPatient's response:| <*Answer_4183*>|6. Repeat the memory phrase.| <*Answer_4178*>|6a. Patient's response:| <*Answer_4184*>||Information contained in this note is based on a self report \nassessment 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. $~\n
\n\n"], ["44", "TIDES FU\n", "\n.|.|TIDES Depression Follow-Up Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nthat apply):| <*Answer_4303*>|14. Risk Assessment/Management comments:| <*Answer_4305*>|15. Patient currently on antidepressant?| <*Answer_4313*>|16. Patient taking antidepressant as \ndirected?| <*Answer_4314*>|17. Last filled Rx:| <*Answer_4315*>|18. Any side-effects from antidepressant?| <*Answer_4316*>|19. Intensity of side-effects:| <*Answer_4317*>|20. \nSide-effect(s) from antidepressant (Check all that apply):| <*Answer_4318*>|21. Antidepressant changes by provider:| <*Answer_4489*>|22. Comments on medication compliance and side-effects| \n<*Answer_4319*>|23. How often does the patient drink?| <*Answer_4331*>|24. Drinks per day:| <*Answer_4334*>|25. Number of days in a month when patient has five or more drinks:| \n<*Answer_4335*>|26. Does patient want alcohol treatment?| <*Answer_4336*>|27. Patient reports significant drug abuse?| <*Answer_4338*>|28. Since the last assessment, has patient felt anxious, \nfrightened or had panic attack(s)?| <*Answer_4340*>|29. Does the patient want a referral for anxiety/panic symptoms?| <*Answer_4341*>|30. PTSD factors (Check all that apply):| \n<*Answer_4343*>|31. Referral for PTSD treatment:| <*Answer_4344*>|32. Comments regarding co-morbidity:| <*Answer_4347*>|33. Previously sent material:| <*Answer_4473*>|34. Self-Help Plan in \nplace?| <*Answer_4474*>|35. Is patient doing self-help activities?| <*Answer_4475*>|36. Changes in barriers to learning (Check all that apply):| <*Answer_4478*>|37. Information offered and \nencouragement (Check all that apply):| <*Answer_4476*>|38. Information to be mailed (Check all that apply):| <*Answer_4477*>|39. Number of Primary Care appointments since last DCM assessment: \n(If no appts between DCM assessments, or clinic cancelled appt, enter zero.)| <*Answer_4490*>|40. Number of Primary Care appointments kept: (Do not count walk-in appointments.)| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Today's Date:| <*Answer_4499*>|1. The patient is feeling:| <*Answer_4487*>|2. Weeks since initial TIDES assessment:| \n<*Answer_4491*>|41. Has an upcoming Primary Care visit been scheduled?| <*Answer_4492*>|42. Date of next scheduled Primary Care visit:| <*Answer_4493*>|43. Number of mental health appointments \nsince last assessment: (If no appts between DCM assessments, or clinic cancelled appt, enter zero.)| <*Answer_4494*>|44. Number of mental health appointments kept:| <*Answer_4495*>|45. Has an \nupcoming mental health visit been scheduled?| <*Answer_4496*>|46. Date of next scheduled mental health visit:| <*Answer_4497*>|47. Mental health appointment types:| <*Answer_4498*>|48. \nComments on self-help and compliance:| <*Answer_4480*>|49. Contact with family indicated?| <*Answer_4500*>|50. Family contact goals (Check all that apply):| <*Answer_4501*>|51. Has patient \nconsented to family contact?| <*Answer_4502*>|52. Care Manager contact since last encounter?| <*Answer_4503*>|53. Number or contacts since last patient assessment:| <*Answer_4504*>|54. Care \nManager had contact with (Check all that apply):| <*Answer_4505*>|55. Discussed with family members:| <*Answer_4506*>|56. Impact on patient's depression care?| <*Answer_4507*>|57. Future \nfamily contact planned?| <*Answer_4508*>|58. Comments for family involvement:| <*Answer_4509*>|59. Depression Care Panel status:| <*Answer_4554*>|60. Depression follow-up in:| \n<*Answer_4511*>|59. Depression Care Panel status:| <*Answer_4553*>|62. Comments for Care Manager follow-up:| <*Answer_4512*>|63. Patient questions and concerns:| <*Answer_4513*>|64. Care \nPlan suggestions (Check all that apply):| <*Answer_4514*>|65. Suggested labs:| <*Answer_4515*>|66. Was case discussed with supervisory psychiatrist?| <*Answer_4516*>|67. Supervising \npsychiatrist input:| <*Answer_4517*>|68. Care Manager comments:| <*Answer_4518*>|69. Patient knows no more calls are coming?| <*Answer_4519*>|70. Patient knows to continue medication(s)?| \n<*Answer_4488*>|3. Most recent PHQ-9: Declined or could not do.| <*Answer_4290*>|4. Most recent PHQ-9 score:| <*Answer_4291*>|5a. Little interest or pleasure:| <*Answer_4543*>|5b. Feeling \n<*Answer_4520*>|71. Relapse strategies discussed (Check all that apply):| <*Answer_4521*>|72. Suggested clinician follow-up (Check all that apply):| <*Answer_4522*>|73. Future Care Manager \nfollow-up (Check all that apply):| <*Answer_4523*>|74. Patient's discharge comments:| <*Answer_4524*>|75. Patient discharge discussed with mental health?| <*Answer_4525*>|76. Psychiatrist's \ninput on patient discharge| <*Answer_4526*>|77. Care Manager's comments on patient discharge:| <*Answer_4527*>|78. Depression diagnosis in problem list or CPT?| <*Answer_4528*>|79. \nDepression diagnosis, ICD-9:| <*Answer_4529*>|80. Provider feedback to:| <*Answer_4530*>|81. Encounter type:| <*Answer_4531*>|82. Encounter length:| <*Answer_4533*>|83. Call history: The \nnumber of attempts to reach the patient for this assessment:| <*Answer_4532*>| $~\ndown, depressed or hopeless:| <*Answer_4544*>|5c. Trouble falling or staying asleep; or sleeping too much:| <*Answer_4545*>|Sleep disturbance:| <*Answer_4293*>|5d. Feeling tired or having \nlittle energy:| <*Answer_4546*>|5e. Poor appetite or overeating:| <*Answer_4547*>|Appetite disturbance:| <*Answer_4294*>|5f. Feeling bad about yourself:| <*Answer_4548*>|5g. Trouble \nconcentrating on things:| <*Answer_4549*>|5h. Moving or speaking slowly; or being fidgety or restless| <*Answer_4550*>|Psycho-motor disturbance:| <*Answer_4295*>|5i. Thoughts that you would \nbe better off dead or of hurting yourself in some way.| <*Answer_4551*>|6. Number of symptoms present:| <*Answer_4296*>|7. Major Depression Disorder trigger symptoms:| <*Answer_4297*>|8. \nSymptom Difficulty: Symptoms make work/home/getting along difficult?| <*Answer_4298*>|9. Comments on depression screening:| <*Answer_4299*>|10. Suicidial ideation (Check all that apply):| \n<*Answer_4300*>|11. Other risk factors for suicide (Check all that apply):| <*Answer_4301*>|12. Is the VA suicide policy initiated?| <*Answer_4302*>|13. Suicidal ideation management (Check all \n
\n\n"], ["45", "CPR3_1R1\n", "\n|CLINICAL PROGRESS REPORT||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \neducation)| <*Answer_4659*>|22. Provided housing support (e.g., location, placement, skills training, meetings)| <*Answer_4660*>|23. Provided vocational support (e.g., placement coaching, \nskills training)| <*Answer_4661*>|24. Other service| <*Answer_4662*>|25. Was your MHICM team the primary provider of mental health services for this veteran during the past six months?| \n<*Answer_4663*>|26. Which pattern of staff contact best describes your direct contacts with this veteran in the past six months?| <*Answer_4664*>|27. What percentage of your face-to-face contacts \nwith this veteran occurred in the community in the past six months?| <*Answer_4665*>|28. How far does this veteran live from your MHICM offices?| <*Answer_4666*>|29. How long does it take MHICM \nstaff to reach this veteran's home?| <*Answer_4667*>|30. Veteran, face-to-face contacts| <*Answer_4668*>|31. Veteran, phone/mail contacts| <*Answer_4669*>|32. Family| <*Answer_4670*>|33. \nNon-family caregivers| <*Answer_4671*>|34. Community agencies| <*Answer_4672*>|35. In the past six months, in a typical week when you saw this veteran, how much total time did your team spend \nproviding direct services to him/her? (Exclude travel time without veteran.)| <*Answer_4673*>|36. ____ and I have a common perception of his/her goals| <*Answer_4674*>|37. The current goals of \nour work together are important for ____| <*Answer_4675*>|38. I am cofident that I can help ____| <*Answer_5099*>|39. We are working towards mutually agreed upon goals| <*Answer_4676*>|40. \n____ and I have built a mutual trust| <*Answer_4677*>|41. We have established a good understanding between us of the kinds of changes that would be good for ____| <*Answer_4678*>|42. Our \nrelationship is unimportant to ____| <*Answer_4679*>|43. Given all you know about this veteran's current life situation, how would you rate his/her present quality of life?| <*Answer_4680*>|44. \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>||||1. Staff Name:| <*Answer_4639*>|2. Today's Date:| <*Answer_4640*>|3. CPR Due Date:| <*Answer_4641*>|4. "Since" Date (IDF or Last CPR Due \nHow has this veteran's community adjustment changed in the past six months?| <*Answer_4681*>|45. What change in psychopathology do you feel this veteran has experienced as a result of his/her \nparticipation in your program?| <*Answer_4682*>|46. Global Assessment Rating:| <*Answer_4683*>|48. In the past six months, was this veteran ever shifted to a lower level of care?| \n<*Answer_4685*>|49. Clinically stable| <*Answer_4686*>|50. Not abusing addictive substances| <*Answer_4687*>|51. Not relying on extensive inpatient or emergency services| <*Answer_4688*>|52. \nCapable of maintaining self in a community living situation| <*Answer_4689*>|53. Independently participating in necessary treatments| <*Answer_4690*>|54. Other criteria:| <*Answer_4691*>|55. \nShifted veteran to lower intensity services within the MHICM team| <*Answer_4692*>|56. Transferred veteran to lower services elsewhere| <*Answer_4693*>|57. Discharged veteran without additional \nservices| <*Answer_4694*>|58. Other treatment changes:| <*Answer_4695*>|59. When did this shift in treatment intensity occur?| <*Answer_4696*>|60. Was this veteran later shifted back to more \nintensive services?| <*Answer_4697*>|61. Real or imminent danger to self or others?| <*Answer_4698*>|62. Psychiatric hospitalization| <*Answer_4699*>|63. Deterioration due to substance \nabuse| <*Answer_4700*>|64. Impaired ability to care for self due to psychosis or stress| <*Answer_4701*>|65. Unwillingness/inability to participate in necessary treatments| \n<*Answer_4702*>|66. Other reasons to restore more intensive services:| <*Answer_4703*>|67. Lower intensity case management services (caseload size > 20 per FTE)| <*Answer_4704*>|68. Day \ntreatment services| <*Answer_4705*>|69. Outpatient mental health services (individual/group therapy)| <*Answer_4706*>|70. Outpatient medication management/support| <*Answer_4707*>|71. \nDate):| <*Answer_4642*>|5. Has this veteran terminated involvement with your program?| <*Answer_4643*>|6. Date of last contact while veteran was in MHICM:| <*Answer_4644*>|7. Veteran is \nSubstance abuse or dual diagnosis program/services| <*Answer_4708*>|72. Residential services (including CRC and therapeutic residence)| <*Answer_4709*>|73. Vocational services (including \nsupported employment)| <*Answer_4710*>|74. Inpatient mental health or medical services| <*Answer_4711*>|75. Nursing home care| <*Answer_4712*>|76. Other services received on a regular \nbasis:| <*Answer_4713*>|77. Did reducing the intensity of case management services for this veteran place him/her at undue risk?| <*Answer_4714*>| $~\ndeceased| <*Answer_4645*>|8. Cause of death| <*Answer_4646*>|9. Date of death:| <*Answer_4647*>|10. Veteran left the area/moved away| <*Answer_4648*>|11. Other reason(s) for termination:| \n <*Answer_4649*>|12. Maintained supportive contact by telephone, mail or casual visits.| <*Answer_4650*>|13. Actively monitored use of resources and/or adherence to treatment.| \n<*Answer_4651*>|14. Provided rehab counselling or skills training.| <*Answer_4652*>|15. Engaged in "psychotherapeutic" relationship using concepts from psychodynamic, behavioral, \ncognitive-behavioral, family-systems or other model of therapy.| <*Answer_4653*>|16. Organized social or recreational activities in the community.| <*Answer_4654*>|17. Provided \neducation/support to family or non-family caregivers.| <*Answer_4655*>|18. Intervened in crisis situation with veteran, family or caregiver.| <*Answer_4656*>|19. Managed psychiatric medications \n(e.g., prescription, pouring, delivery)| <*Answer_4657*>|20. Provided screening or care for medical problems.| <*Answer_4658*>|21. Provided substance abuse treatment (e.g., contracting, \n
\n\n"], ["46", "VAMSTA-A\n", "\n.| .| VETERANS AFFAIRS MILITARY STRESS TREATMENT ASSESSMENT FORM A| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \ncan range from 0% to 100%)| <*Answer_4729*>| 14. Are you currently applying for or planning to apply for service connection for PTSD or for an increase in percent service disability for PTSD?| \n <*Answer_4730*>| 15. Are you currently taking any medications for PTSD or for other emotional problems that have been prescribed for you by a psychiatrist or other physician?| <*Answer_4731*>| \n16a. Outpatient PTSD treatment from any VA medical center| <*Answer_4732*>| 16b. Outpatient PTSD treatment from a Vet Center| <*Answer_4733*>| 16c. Outpatient PTSD treatment from any non-VA \nprogram| <*Answer_4734*>| 16d. Outpatient treatment of substance use problems from a VA addictions program| <*Answer_4735*>| 16e. Outpatient treatment of substance use problems from a non-VA \naddictions program| <*Answer_4736*>| 16f. Self-help groups for substance use problems (such as AA or NA)| <*Answer_4737*>| 16g. Individual meetings with a chaplain in the VA while you were an \noutpatient| <*Answer_4738*>| 16h. Individual meetings with a chaplain in the VA while you were an inpatient| <*Answer_4739*>| 16i. Individual meetings with a member of the clergy outside of \nthe VA| <*Answer_4740*>| 16j. Emergency room visits at any VA or non-VA medical center for PTSD-related problems| <*Answer_4741*>| 16k. Inpatient or residential admission for PTSD at a VA \nMedical Center for any PTSD-related problem (NOT substance use problems)| <*Answer_4742*>| 16l. Inpatient or residential admission at a VA Medical Center for substance use problems| \n<*Answer_4743*>| 16m. Inpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt| <*Answer_4744*>| 16n. Inpatient or residential admission \nat a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt| <*Answer_4745*>| 17. I have nightmares of experiences in the military that really happened.| \nSSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Questions and Answers| | 1. Type of Specialized PTSD Program:| <*Answer_4715*>| 2. Admission \n <*Answer_4746*>| 18. Lately, I have felt like killing myself.| <*Answer_4747*>| 19. I fall asleep, stay asleep and only awaken when it's time to get up.| <*Answer_4748*>| 20. My dreams at \nnight are so real that I waken in a cold sweat and force myself to stay awake.| <*Answer_4749*>| 21. I feel like I cannot go on.| <*Answer_4750*>| 22. I do not laugh or cry at the same things \nother people do.| <*Answer_4751*>| 23. I enjoy the company of others.| <*Answer_4752*>| 24. I wonder why I am still alive when others died in the military.| <*Answer_4753*>| 25. \nUnexpected noises make me jump.| <*Answer_4754*>| 26. There are times when I used alcohol (or other drugs) to help me sleep or make me forget about things that happened while I was in the \nservice.| <*Answer_4755*>| 27. I lose my cool and explode over minor everyday things.| <*Answer_4756*>| 28. I have a hard time expressing my feelings, even to the people I care about.| \n<*Answer_4757*>| 29. When I think of some of the things that I did in the military, I wish I were dead.| <*Answer_4758*>| 30a. Repeated, disturbing memories, thoughts, or images of a stressful \nmilitary experience?| <*Answer_4759*>| 30b. Repeated, disturbing dreams of a stressful military experience?| <*Answer_4760*>| 30c. Suddenly acting or feeling as if a stressful military \nexperience were happening again (as if you were reliving it)?| <*Answer_4761*>| 30d. Feeling very upset when something reminded you of a stressful military experience?| <*Answer_4762*>| 30e. \nHaving physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?| <*Answer_4763*>| 30f. Avoiding thinking about or \ntalking about a stressful military experience or avoiding having feelings related to it?| <*Answer_4764*>| 30g. Avoiding activities or situations because they reminded you of a stressful military \nDate to this Program (mm/dd/yyyy):| <*Answer_4716*>| 3. Date of this Report (mm/dd/yyyy):| <*Answer_4717*>| 4. What is the highest year of education that you completed? (For example, "12" \nexperience?| <*Answer_4765*>| 30h. Trouble remembering important parts of a stressful military experience?| <*Answer_4766*>| 30i. Loss of interest in activities that you used to enjoy?| \n<*Answer_4767*>| 30j. Feeling distant or cut off from other people?| <*Answer_4768*>| 30k. Feeling emotionally numb or being unable to have loving feelings for those close to you?| \n<*Answer_4769*>| 30l. Feeling as if your future somehow will be cut short?| <*Answer_4770*>| 30m. Trouble falling or staying asleep?| <*Answer_4771*>| 30n. Feeling irritable or having angry \noutbursts?| <*Answer_4772*>| 30o. Having difficulty concentrating?| <*Answer_4773*>| 30p. Being "superalert" or watchful or on guard?| <*Answer_4774*>| 30q. Feeling jumpy or easily \nstartled?| <*Answer_4775*>| 31. How well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?| <*Answer_4776*>| 32a. Little interest or \npleasure in doing things| <*Answer_4777*>| 32b. Feeling down, depressed, or hopeless.| <*Answer_4778*>| 32c. Trouble falling or staying asleep, or sleeping too much.| <*Answer_4779*>| \n32d. Feeling tired or having little energy.| <*Answer_4780*>| 32e. Poor appetite or overeating.| <*Answer_4781*>| 32f. Feeling bad about yourself-or that you are a failure or have let \nyourself or your family down.| <*Answer_4782*>| 32g. Trouble concentrating on things, such as reading the newspaper or watching television.| <*Answer_4783*>| 32h. Moving or speaking so slowly \nthat other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.| <*Answer_4784*>| 32i. Thoughts that you would be \nbetter off dead or hurting yourself in some way.| <*Answer_4785*>| 33. During the past month, my desire to make an active suicide attempt.| <*Answer_4786*>| 34. During the past month, I \nfor high school graduate or GED, "16" for college bachelor's degree, "20" for advanced professional degree.)| <*Answer_4718*>| 5. What is your race or ethnic ancestry?| <*Answer_4719*>| 6. \nthought of suicide.| <*Answer_4787*>| 35. During the past month, when I thought of suicide.| <*Answer_4788*>| 36. Have you attempted suicide at any time in the last 4 months?| \n<*Answer_4789*>| 37. Do you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?| <*Answer_4790*>| \n38. During the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.| \n<*Answer_4791*>| 39. During the past month, how would you rate your sleep quality overall?| <*Answer_4792*>| 40. Did your use of alcohol in the past 4 months lead to any problems in your life, \nsuch as in meeting your responsibilities or in your relationships with other people?| <*Answer_4793*>| 41. Did you have to demonstrate to the staff of this program that you could be sober for a \nfew weeks before they would begin treating you?| <*Answer_4794*>| 42. How many days in the 4 months prior to beginning this program did you drink alcohol at all?| <*Answer_4795*>| 42a. How \nmany days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?| <*Answer_4796*>| 43a. I \nhave been unhappy because of my drinking.| <*Answer_4797*>| 43b. I have taken foolish risks when I have been drinking.| <*Answer_4798*>| 43c. My physical health has been harmed by my \ndrinking.| <*Answer_4799*>| 43d. My drinking has gotten in the way of my growth as a person.| <*Answer_4800*>| 43e. My drinking has damaged my social life, popularity, or reputation.| \n<*Answer_4801*>| 43f. I have spent too much or lost a lot of money because of my drinking.| <*Answer_4802*>| 43g. I have had an automobile accident or injured myself while drinking or while \nDid you ever serve in a war zone?| <*Answer_4720*>| 6a. Check all war zones that apply:| <*Answer_4721*>| 7. Did you ever receive friendly or hostile fire from small arms, artillery, rockets, \nintoxicated.| <*Answer_4803*>| 44. Did your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or \nin your relationships with other people? | <*Answer_4804*>| 45. Did you have to demonstrate to the staff of this program that you could be clean (that is, drug free) for a few weeks before \nthey would begin treating you?| <*Answer_4805*>| 46. How many days in the past 4 months prior to beginning this program did you use drugs at all?| <*Answer_4806*>| 47a. Because of my drug \nuse, I have not eaten properly.| <*Answer_4807*>| 47b. I have failed to do what is expected of me because of my drug use.| <*Answer_4808*>| 47c. I have felt guilty or ashamed because of my \ndrug use.| <*Answer_4809*>| 47d. When using drugs, I have done impulsive things that I regretted later.| <*Answer_4810*>| 47e. I have had money problems because of my drug use.| \n<*Answer_4811*>| 47f. My family has been hurt by my drug use.| <*Answer_4812*>| 47g. A friendship or close relationship has been damaged by my drug use.| <*Answer_4813*>| 48. Overall, how \nwould you rate your health during the past 4 weeks?| <*Answer_4814*>| 49. During the past 4 weeks, how much did physical health problems limit your usual physical activities (such as walking or \nclimbing stairs)?| <*Answer_4815*>| 50. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of your physical health?| \n<*Answer_4816*>| 51. How much bodily pain have you had during the past 4 weeks?| <*Answer_4817*>| 52. During the past 4 weeks, how much energy did you have?| <*Answer_4818*>| 53. During the \npast 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?| <*Answer_4819*>| 54. During the past 4 weeks, how much have you \nmortars or bombs?| <*Answer_4722*>| 8. Were you ever a prisoner of war?| <*Answer_4723*>| 9. Did you ever observe others or participate yourself in atrocities, such as torturing prisoners, \nbeen bothered by emotional problems (such as feeling anxious, depressed, or irritable)?| <*Answer_4820*>| 55. During the past 4 weeks, how much did personal or emotional problems keep you from \ndoing your usual work, school or other daily activities?| <*Answer_4821*>| 56. How many days have you experienced medical problems in the past 30 days? (Include both major and minor ailments \nexcept temporary alcohol or drug problems. If no problems, enter "0"| <*Answer_4822*>| 57. How troubled or bothered have you been by these medical problems in the past 30 days?| \n<*Answer_4823*>| 58. How important to you now is additional treatment beyond what you have been receiving all along for these medical problems?| <*Answer_4824*>| 59. On average, about how many \ncigarettes a day do you smoke? (1 pack is 20 cigarettes.)| <*Answer_4825*>| 60. Over the past month, how often have you engaged in regular activities (for example, brisk walking, jogging, \nbicycling, etc.) long enough to work up a sweat?| <*Answer_4826*>| 61. 5ave you used any health care services for your physical health within the last year?| <*Answer_4827*>| 62. I find \nstrength and comfort in my religion.| <*Answer_4828*>| 63. My religion provides me with satisfying answers to questions about the meaning or purpose of life.| <*Answer_4829*>| 64. My whole \napproach to life is based on my religion.| <*Answer_4830*>| 65. What religion offers me most is comfort in times of trouble and sorrow.| <*Answer_4831*>| 66. I go to church mainly because I \nenjoy seeing people I know there.| <*Answer_4832*>| 67. I feel God's presence.| <*Answer_4833*>| 68. I feel deep inner peace or harmony.| <*Answer_4834*>| 69. I feel God's love for me, \ndirectly or through others.| <*Answer_4835*>| 70. I am spiritually touched by the beauty of creation.| <*Answer_4836*>| 71. How often do you attend religious services?| <*Answer_4837*>| \nmutilating enemy bodies, or harming civilians?| <*Answer_4724*>| 10. Were you ever sexually assaulted while you were in the military?| <*Answer_4725*>| 11. Were you ever threatened with \n72. How often do you pray or meditate privately in places other than at a house of worship?| <*Answer_4838*>| 73. What is your employment status?| <*Answer_4839*>| 74. How many days did you \nwork for pay during the past 30 days?| <*Answer_4840*>| 75. During the past 4 months, how often have you had friends or relatives over to your home?| <*Answer_4841*>| 76. About how often have \nyou visited with friends or relatives at their homes during the past 4 months?| <*Answer_4842*>| 77. During the past 4 months, about how often did you go out with friends or relatives (for \nexample, meet for coffee, go to a movie, bowl, go to church)?| <*Answer_4843*>| 78. About how often did you have telephone, mail, or computer contact with friends or relatives during the past 4 \nmonths?| <*Answer_4844*>| 79. Did you do any of these during the last 4 months? (Check all that apply)| <*Answer_4845*>| 80. Got out of the house...| <*Answer_4846*>| 81. Did an activity \nfor pleasure or fun (for example, going to a movie, going fishing, playing chess)...| <*Answer_4847*>| 82. Did chores out in the community (for example, shopping, going to bank)...| \n<*Answer_4848*>| 83a. Your life as a whole; that is, your health, your relationships with other people, and your recreational activities overall?| <*Answer_4849*>| 83b. The living arrangements \nwhere you live?| <*Answer_4850*>| 83c. The way you spend your free time?| <*Answer_4851*>| 83d. The amount of time you spend with other people?| <*Answer_4852*>| 83e. The amount of fun \nyou have?| <*Answer_4853*>| 83f. The way things are in general between you and your family?| <*Answer_4854*>| 83g. The amount of friendship in your life?| <*Answer_4855*>| 83h. How \ncomfortable and well-off you are financially?| <*Answer_4856*>| 83i. Your physical condition?| <*Answer_4857*>| 83j. Your emotional well-being?| <*Answer_4858*>| 84. How easy or difficult \nsexual assault in the military although you were never actually assaulted?| <*Answer_4726*>| 12. Were you ever sexually harassed in the military, although you were never sexually assaulted or \ndo you expect it to be to open up about yourself in treatment?| <*Answer_4859*>| 85. How effective do you think your care is likely to be in helping you achieve your goals for entering \ntreatment?| <*Answer_4860*>| | | 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 \nverified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nthreatened with assault?| <*Answer_4727*>| 13. Have you been certified by the VA as service connected for PTSD?| <*Answer_4728*>| 13a. What is your disability percentage? (Percent disability \n
\n\n"], ["47", "VAMSTA-B\n", "\n.|.|VETERANS AFFAIRS MILITARY STRESS TREATMENT ASSESSMENT, FORM B|Follow-Up Questionnaire||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: \n <*Answer_4890*>|1n. Inpatient or residential admission at a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt| <*Answer_4891*>|2. How satisfied \noverall are you with the care you received from the specialized PTSD program?| <*Answer_5007*>|3. How satisfied specifically are you with the changes you've made as a result of participating in \ntreatment?| <*Answer_5008*>|4. How satisfied are you specifically with the interactions you had with program staff?| <*Answer_5009*>|5. How satisfied are you specifically with the waiting time \nfor treatment by this program?| <*Answer_5010*>|6. How satisfied are you specifically with the arrangements to make women comfortable in coming to this program for treatment?| \n<*Answer_5011*>|7. I have nightmares of experiences in the military that really happened.| <*Answer_4892*>|8. Lately, I have felt like killing myself.| <*Answer_4893*>|9. I fall asleep, stay \nasleep and only awaken when it's time to get up.| <*Answer_4894*>|10. My dreams at night are so real that I waken in a cold sweat and force myself to stay awake.| <*Answer_4895*>|11. I feel \nlike I cannot go on.| <*Answer_4896*>|12. I do not laugh or cry at the same things other people do.| <*Answer_4897*>|13. I enjoy the company of others.| <*Answer_4898*>|14. I wonder why I am \nstill alive when others died in the military.| <*Answer_4899*>|15. Unexpected noises make me jump.| <*Answer_4900*>|16. There are times when I used alcohol (or other drugs) to help me sleep or \nmake me forget about things that happened while I was in the service.| <*Answer_4901*>|17. I lose my cool and explode over minor everyday things.| <*Answer_4902*>|18. I have a hard time \nexpressing my feelings, even to the people I care about.| <*Answer_4903*>|19. When I think of some of the things that I did in the military, I wish I were dead.| <*Answer_4904*>|20a. Repeated, \n<.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Type of Specialized PTSD Program:| <*Answer_4861*>|Admission Date to \ndisturbing memories, thoughts, or images of a stressful military experience?| <*Answer_4905*>|20b. Repeated, disturbing dreams of a stressful military experience?| <*Answer_4906*>|20c. Suddenly \nacting or feeling as if a stressful military experience were happening again (as if you were reliving it)?| <*Answer_4907*>|20d. Feeling very upset when something reminded you of a stressful \nmilitary experience?| <*Answer_4908*>|20e. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?| \n<*Answer_4909*>|20f. Avoiding thinking about or talking about a stressful military experience or avoiding having feelings related to it?| <*Answer_4910*>|20g. Avoiding activities or situations \nbecause they reminded you of a stressful military experience?| <*Answer_4911*>|20h. Trouble remembering important parts of a stressful military experience?| <*Answer_4912*>|20i. Loss of \ninterest in activities that you used to enjoy?| <*Answer_4913*>|20j. Feeling distant or cut off from other people?| <*Answer_4914*>|20k. Feeling emotionally numb or being unable to have loving \nfeelings for those close to you?| <*Answer_4915*>|20l. Feeling as if your future somehow will be cut short?| <*Answer_4916*>|20m. Trouble falling or staying asleep?| <*Answer_4917*>|20n. \nFeeling irritable or having angry outbursts?| <*Answer_4918*>|20o. Having difficulty concentrating?| <*Answer_4919*>|20p. Being "superalert" or watchful or on guard?| <*Answer_4920*>|20q. \nFeeling jumpy or easily startled?| <*Answer_4921*>|21. How well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?| \n<*Answer_4922*>|22a. Little interest or pleasure in doing things| <*Answer_4923*>|22b. Feeling down, depressed, or hopeless.| <*Answer_4924*>|22c. Trouble falling or staying asleep, or sleeping \nthis Program (mm/dd/yyyy):| <*Answer_4862*>|Date of this Report (mm/dd/yyyy):| <*Answer_4863*>|1a. Outpatient PTSD treatment from any VA medical center| <*Answer_4878*>|1b. Outpatient PTSD \ntoo much.| <*Answer_4925*>|22d. Feeling tired or having little energy.| <*Answer_4926*>|22e. Poor appetite or overeating.| <*Answer_4927*>|22f. Feeling bad about yourself-or that you are a \nfailure or have let yourself or your family down.| <*Answer_4928*>|22g. Trouble concentrating on things, such as reading the newspaper or watching television.| <*Answer_4929*>|22h. Moving or \nspeaking so slowly that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.| <*Answer_4930*>|22i. Thoughts that \nyou would be better off dead or hurting yourself in some way.| <*Answer_4931*>|23. During the past month, my desire to make an active suicide attempt.| <*Answer_4932*>|24. During the past \nmonth, I thought of suicide.| <*Answer_4933*>|25. During the past month, when I thought of suicide.| <*Answer_4934*>|26. Have you attempted suicide at any time in the last 4 months?| \n<*Answer_4935*>|27. Do you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?| <*Answer_4936*>|28. \nDuring the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.| \n<*Answer_4937*>|29. During the past month, how would you rate your sleep quality overall?| <*Answer_4938*>|30. Did your use of alcohol in the past 4 months lead to any problems in your life, such \nas in meeting your responsibilities or in your relationships with other people?| <*Answer_4939*>|31. How many days in the 4 months prior to beginning this program did you drink alcohol at all?| \n<*Answer_4941*>|31a. How many days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?| \ntreatment from a Vet Center| <*Answer_4879*>|1c. Outpatient PTSD treatment from any non-VA program| <*Answer_4880*>|1d. Outpatient treatment of substance use problems from a VA addictions \n<*Answer_4942*>|32a. I have been unhappy because of my drinking.| <*Answer_4943*>|32b. I have taken foolish risks when I have been drinking.| <*Answer_4944*>|32c. My physical health has been \nharmed by my drinking.| <*Answer_4945*>|32d. My drinking has gotten in the way of my growth as a person.| <*Answer_4946*>|32e. My drinking has damaged my social life, popularity, or \nreputation.| <*Answer_4947*>|32f. I have spent too much or lost a lot of money because of my drinking.| <*Answer_4948*>|32g. I have had an automobile accident or injured myself while drinking \nor while intoxicated.| <*Answer_4949*>|33. Did your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your \nresponsibilities or in your relationships with other people? | <*Answer_4950*>|34. How many days in the past 4 months prior to beginning this program did you use drugs at all?| \n<*Answer_4952*>|35a. Because of my drug use, I have not eaten properly.| <*Answer_4953*>|35b. I have failed to do what is expected of me because of my drug use.| <*Answer_4954*>|35c. I have \nfelt guilty or ashamed because of my drug use.| <*Answer_4955*>|35d. When using drugs, I have done impulsive things that I regretted later.| <*Answer_4956*>|35e. I have had money problems \nbecause of my drug use.| <*Answer_4957*>|35f. My family has been hurt by my drug use.| <*Answer_4958*>|35g. A friendship or close relationship has been damaged by my drug use.| \n<*Answer_4959*>|36. Overall, how would you rate your health during the past 4 weeks?| <*Answer_4960*>|37. During the past 4 weeks, how much did physical health problems limit your usual physical \nactivities (such as walking or climbing stairs)?| <*Answer_4961*>|38. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of \nprogram| <*Answer_4881*>|1e. Outpatient treatment of substance use problems from a non-VA addictions program| <*Answer_4882*>|1f. Self-help groups for substance use problems (such as AA or NA)| \nyour physical health?| <*Answer_4962*>|39. How much bodily pain have you had during the past 4 weeks?| <*Answer_4963*>|40. During the past 4 weeks, how much energy did you have?| \n<*Answer_4964*>|41. During the past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?| <*Answer_4965*>|42. During the past \n4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?| <*Answer_4966*>|43. During the past 4 weeks, how much did personal or emotional \nproblems keep you from doing your usual work, school or other daily activities?| <*Answer_4967*>|44. How many days have you experienced medical problems in the past 30 days? (Include both major \nand minor ailments except temporary alcohol or drug problems. If no problems, enter "0"| <*Answer_4968*>|45. How troubled or bothered have you been by these medical problems in the past 30 days?| \n <*Answer_4969*>|46. How important to you now is additional treatment beyond what you have been receiving all along for these medical problems?| <*Answer_4970*>|47. On average, about how many \ncigarettes a day do you smoke? (1 pack is 20 cigarettes.)| <*Answer_4971*>|48. Over the past month, how often have you engaged in regular activities (for example, brisk walking, jogging, \nbicycling, etc.) long enough to work up a sweat?| <*Answer_4972*>|49. 5ave you used any health care services for your physical health within the last year?| <*Answer_4973*>|50. I find strength \nand comfort in my religion.| <*Answer_4974*>|51. My religion provides me with satisfying answers to questions about the meaning or purpose of life.| <*Answer_4975*>|52. My whole approach to \nlife is based on my religion.| <*Answer_4976*>|53. What religion offers me most is comfort in times of trouble and sorrow.| <*Answer_4977*>|54. I go to church mainly because I enjoy seeing \n <*Answer_4883*>|1g. Individual meetings with a chaplain in the VA while you were an outpatient| <*Answer_4884*>|1h. Individual meetings with a chaplain in the VA while you were an inpatient| \npeople I know there.| <*Answer_4978*>|55. I feel God's presence.| <*Answer_4979*>|56. I feel deep inner peace or harmony.| <*Answer_4980*>|57. I feel God's love for me, directly or through \nothers.| <*Answer_4981*>|58. I am spiritually touched by the beauty of creation.| <*Answer_4982*>|59. How often do you attend religious services?| <*Answer_4983*>|60. How often do you pray \nor meditate privately in places other than at a house of worship?| <*Answer_4984*>|61. What is your employment status?| <*Answer_4985*>|62. How many days did you work for pay during the past 30 \ndays?| <*Answer_4986*>|63. During the past 4 months, how often have you had friends or relatives over to your home?| <*Answer_4987*>|64. About how often have you visited with friends or \nrelatives at their homes during the past 4 months?| <*Answer_4988*>|65. During the past 4 months, about how often did you go out with friends or relatives (for example, meet for coffee, go to a \nmovie, bowl, go to church)?| <*Answer_4989*>|66. About how often did you have telephone, mail, or computer contact with friends or relatives during the past 4 months?| <*Answer_4990*>|67. Did \nyou do any of these during the last 4 months? (Check all that apply)| <*Answer_4991*>|68. Got out of the house...| <*Answer_4992*>|69. Did an activity for pleasure or fun (for example, going \nto a movie, going fishing, playing chess)...| <*Answer_4993*>|70. Did chores out in the community (for example, shopping, going to bank)...| <*Answer_4994*>|71a. Your life as a whole; that is, \nyour health, your relationships with other people, and your recreational activities overall?| <*Answer_4995*>|71b. The living arrangements where you live?| <*Answer_4996*>|71c. The way you \nspend your free time?| <*Answer_4997*>|71d. The amount of time you spend with other people?| <*Answer_4998*>|71e. The amount of fun you have?| <*Answer_4999*>|71f. The way things are in \n<*Answer_4885*>|1i. Individual meetings with a member of the clergy outside of the VA| <*Answer_4886*>|1j. Emergency room visits at any VA or non-VA medical center for PTSD-related problems| \ngeneral between you and your family?| <*Answer_5000*>|71g. The amount of friendship in your life?| <*Answer_5001*>|71h. How comfortable and well-off you are financially?| \n<*Answer_5002*>|71i. Your physical condition?| <*Answer_5003*>|71j. Your emotional well-being?| <*Answer_5004*>|72. How effective has the care you received from this specialized PTSD program \nbeen in helping you achieve your goals for entering treatment?| <*Answer_5005*>|73. How easy or difficult has it been for you to open up about yourself in treatment?| <*Answer_5006*>|74. How \nlikeable have you found your therapist(s) to be personally?| <*Answer_5012*>|75. How much competence and expertise has your therapist(s) shown in treating you?| <*Answer_5013*>|76. How much \nhave you and your therapist(s) agreed on the methods and goals of your treatment?| <*Answer_5014*>|77. How friendly and caring has the staff been toward you?| <*Answer_5015*>|78. How much has \nyour emotional or psychological health improved or not improved since you began treatment in this program?| <*Answer_5016*>|79. What is your treatment status currently?| <*Answer_5017*>| $~\n<*Answer_4887*>|1k. Inpatient or residential admission for PTSD at a VA Medical Center for any PTSD-related problem (NOT substance use problems)| <*Answer_4888*>|1l. Inpatient or residential \nadmission at a VA Medical Center for substance use problems| <*Answer_4889*>|1m. Inpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt| \n
\n\n"], ["48", "TBI FOLLOW-UP\n", "\n.|.|Traumatic Brain Injury: Follow-Up Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nthe ground" to protect yourself.)| <*Answer_5034*>| 5-D-4. Did you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations, \nbreathing toxic fumes, or crush injuries from structures falling onto you? | <*Answer_5036*>| 5-D-5. Type of blast exposures: (Check all that apply)| <*Answer_5038*>| 5-E. Blunt trauma \nother than from blast/vehicular injury, e.g., assault, blunt force or object hitting head| <*Answer_5230*>||6. Did you lose consciousness immediately after any of these experiences?| \n<*Answer_5040*>| 6-A. If yes, estimate the duration of longest period of loss of consciousness?| <*Answer_5041*>||7. Did you have a period of disorientation or confusion immediately following \nthe incident?| <*Answer_5042*>| 7-A. If yes, estimate the duration of longest period of disorientation or confusion.| <*Answer_5043*>||8. Did you experience a period of memory loss \nimmediately before or after the incident?| <*Answer_5044*>| 8-A. If yes, estimate the duration of longest period of memory loss (Post Traumatic Amnesia (PTA))| <*Answer_5045*>||9. During \nthis/these experience(s), did an object penetrate your skull/cranium:| <*Answer_5046*>||10. If you have had a new injury, have you seen any health care providers (doctors/therapists) as a result \nof the new head injury?| <*Answer_5492*>| 10-A. Did the provider you saw for your new injury change your medications in any way (new type or change in dosage)?| <*Answer_5493*>||11. Please \nrate the following symptoms with regard to how they have affected you over the past 30 days.| 11-A. Feeling Dizzy:| <*Answer_5047*>| 11-B. Loss of balance:| <*Answer_5048*>| 11-C. Poor \ncoordination, clumsy:| <*Answer_5049*>| 11-D. Headaches:| <*Answer_5050*>| 11-E. Nausea:| <*Answer_5051*>| 11-F. Vision problems, blurring, trouble seeing:| <*Answer_5052*>| 11-G. \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||A. Chief Complaint:| <*Answer_5018*>|B. History of Present Illness, or Interval History since last visit| \nSensitivity to light:| <*Answer_5053*>| 11-H. Hearing difficulty:| <*Answer_5054*>| 11-I. Sensitivity to noise:| <*Answer_5055*>| 11-J. Numbness or tingling in parts of my body:| \n<*Answer_5056*>| 11-K. Change in ability to taste and/or smell:| <*Answer_5057*>| 11-L. Loss of appetite or increase appetite:| <*Answer_5058*>| 11-M. Poor concentration, can't pay \nattention:| <*Answer_5059*>| 11-N. Forgetfullness, can't remember things:| <*Answer_5060*>| 11-O. Difficutly making decisions:| <*Answer_5061*>| 11-P. Slowed thinking, difficulty \ngetting organized, can't finish things:| <*Answer_5062*>| 11-Q. Fatigue, loss of energy, getting tired easily:| <*Answer_5063*>| 11-R. Difficulty falling or staying asleep:| \n<*Answer_5064*>| 11-S. Feeling anxious or tense:| <*Answer_5065*>| 11-T. Feeling depressed or sad:| <*Answer_5066*>| 11-U. Irritability, easily annoyed:| <*Answer_5067*>| 11-V. Poor \nfrustration tolerance, feeling easily overwhelmed by things:| <*Answer_5068*>||12. Overall, in the last 30 days how much did these difficulties (symptoms?) interfere with your life?| \n<*Answer_5069*>| 12-A. In what areas of your life are you having difficulties because of these symptoms?| <*Answer_5070*>||13. In the last 30 days, have you had any problems with pain?| \n<*Answer_5071*>| 13-A. Location of pain: (Check all that apply)| <*Answer_5072*> | 13-B. In the last 30 days, how much did pain interfere with your life?| <*Answer_5074*>| 13-C. In what \nareas of your life are you having difficulties because of pain?| <*Answer_5075*>||14. Since your last evaluation, are your overall symptoms:| <*Answer_5076*>|15. Additional comments regarding \ncurrent symptoms/functional status:| <*Answer_5077*>|16. System Review:| <*Answer_5078*>|17. Physical Exam:| <*Answer_5079*>|18. Current medications:| <*Answer_5080*>|19. Professional \n<*Answer_5019*>||1. Change in Marital Status:| <*Answer_5020*>||2. Highest educational level achieved:| <*Answer_5021*>| 2-A. Current school or training status:| <*Answer_5022*>||3. \nconclusion/assessment:| <*Answer_5081*>||20. Has the patient experienced a new TBI since their last diagnosis?| <*Answer_5082*>| 20-A. In your clinical judgment the current clinical symptom \npresentation is most consistent with:| <*Answer_5231*>||21. Follow up plan: (Check all that apply)| <*Answer_5084*>|22. Details of plan:| <*Answer_5085*>| | The information contained in \nnote created from the template for a TBI Follow up Evaluation, and may only contain a portion of the full evaluation. A full TBI Follow Up Evaluation contains a history of patient's present \nillness/symptoms, focused review of body systems, targeted physical exam, confirming the diagnosis of TBI, and a follow up/treatment plan. Full follow up evaluation documentation should be attached \nto this note via an addendum if the free text boxes in the template were not utilized to capture this information. $~\nCurrent employment status:| <*Answer_5023*>||4. Experienced head injury since prior evaluation?| <*Answer_5024*>| 4-A. Month of most recent head injury:| <*Answer_5228*>| 4-B. Year of \nmost recent head injury:| <*Answer_5229*>||5. Cause of injury: | 5-A. Bullet| <*Answer_5026*>| 5-B. Vehicular:| <*Answer_5027*>| 5-C. Fall:| <*Answer_5028*>| 5-D. Blast:| \n<*Answer_5029*>| 5-D-1. When a high-explosive bomb or IED goes off there is a "blast wave" which is a wave of highly compressed gas that may feel almost like being smashed into a wall. Do you \nremember experiencing this or were told that you experienced it? | <*Answer_5030*>| 5-D-1-A. Estimated distance from closest blast:| <*Answer_5031*>| 5-D-2. This "blast wave" is \nfollowed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough to the blast to be "peppered" or hit by such debris, shrapnel, or other \nitems? | <*Answer_5032*>| 5-D-3. Were you thrown to the ground or against some stationary object like a wall, vehicle or inside a vehicle by the explosion? (This is not asking if you "ducked to \n
\n\n"], ["49", "MHLC\n", "\n.|.|Multidimensional Health Locus of Control: Form C||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5506*>|14. Following doctor's orders to the letter is the best way to keep my condition from getting any worse.| <*Answer_5507*>|15. If my condition worsens, it's a matter of fate.| \n<*Answer_5508*>|16. If I am lucky, my condition will get better.| <*Answer_5509*>|17. If my condition takes a turn for the worse, it is because I have not been taking proper care of myself.| \n<*Answer_5510*>|18. The type of help I receive from other people determines how soon my condition improves.| <*Answer_5511*>| | | $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||MHLC Form C Scores| INTERNAL (range 6-36): <-INTERNAL->| CHANCE (range 6-36): <-CHANCE->| DOCTORS (range 3-18): \n<-DOCTORS->| OTHER PEOPLE (range 3-18): <-OTHER PEOPLE->||Questions and Answers|1. If my condition worsens, it is my own behavior which determines how soon I will feel better again.| \n<*Answer_5494*>|2. As to my condition, what will be will be.| <*Answer_5495*>|3. If I see my doctor regularly, I am less likely to have problems with my condition.| <*Answer_5496*>|4. Most \nthings that affect my condition happen to me by chance.| <*Answer_5497*>|5. Whenever my condition worsens, I should consult a medically trained professional.| <*Answer_5498*>|6. I am directly \nresponsible for my condition getting better or worse.| <*Answer_5499*>|7. Other people play a big role in whether my condition improves, stays the same, or gets worse.| <*Answer_5500*>|8. \nWhatever goes wrong with my condition is my own fault.| <*Answer_5501*>|9. Luck plays a big part in determining how my condition improves.| <*Answer_5502*>|10. In order for my condition to \nimprove, it is up to other people to see that the right things happen.| <*Answer_5503*>|11. Whatever improvement occurs with my condition is largely a matter of good fortune.| \n<*Answer_5504*>|12. The main thing which affects my health is what I myself do.| <*Answer_5505*>|13. I deserve the credit when my condition improves and the blame when it gets worse.| \n
\n\n"], ["5", "File: 601.71, IEN: 100108\n", "\n WHYMPI Date Given: <.Date Given.> Clinician: <.Staff: Ordered By.> Location: <.Location.> Veteran: <.Patient Name: Last, First.> SSN: <.Patient: SSN.> DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>) Gender: <.Patient: Gender.> This is a sample report to help you get started. Use the right button of the mouse to display editing options (these also appear in the "Tools"menu and the Navigation panel). Instructions appear in the lower panel and change depending upon the location of the mouse. You will need to delete this paragraph later. <_Script_1_> $~ <_Script_1_>=Please indicate who your significant other is:`101620`7. Other (please describe)`100985`Equals``````The name was not in list.~\n
\n\n"], ["50", "MHLC-C\n", "\n.| .| Multidimensional Health Locus of Control: Form C| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nsee that the right things happen.| <*Answer_5390*>| 11. Whatever improvement occurs with my condition is largely a matter of good fortune.| <*Answer_5391*>| 12. The main thing which affects \nmy condition is what I myself do.| <*Answer_5392*>| 13. I deserve the credit when my condition improves and the blame when it gets worse.| <*Answer_5393*>| 14. Following doctor's orders to \nthe letter is the best way to keep my condition from getting any worse.| <*Answer_5394*>| 15. If my condition worsens, it's a matter of fate.| <*Answer_5395*>| 16. If I am lucky, my condition \nwill get better.| <*Answer_5396*>| 17. If my condition takes a turn for the worse, it is because I have not been taking proper care of myself.| <*Answer_5397*>| 18. The type of help I receive \nfrom other people determines how soon my condition improves.| <*Answer_5398*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | MHLC-C| | Internal: <-Internal->| Range: 6-36. High score indicates belief that one's behavior \ncontrols one's health. | | Chance: <-Chance->| Range: 6-36. High score indicates belief that health is controlled by chance, luck or fate. | | Doctors: <-Doctors->| Range: \n3-18. High score indicates belief that health is controlled by health professionals.| | Other People: <-Other People->| Range: 3-18. High score indicates belief that significant others \ndetermine one's health.| | Questions and Answers| | 1. If my condition worsens, it is my own behavior which determines how soon I will feel better again.| <*Answer_5381*>| 2. As to my condition, \nwhat will be will be.| <*Answer_5382*>| 3. If I see my doctor regularly, I am less likely to have problems with my condition.| <*Answer_5383*>| 4. Most things that affect my condition happen \nto me by chance.| <*Answer_5384*>| 5. Whenever my condition worsens, I should consult a medically trained professional.| <*Answer_5385*>| 6. I am directly responsible for my condition getting \nbetter or worse.| <*Answer_5386*>| 7. Other people play a big role in whether my condition improves, stays the same, or gets worse.| <*Answer_5387*>| 8. Whatever goes wrong with my condition \nis my own fault.| <*Answer_5388*>| 9. Luck plays a big part in determining how my condition improves.| <*Answer_5389*>| 10. In order for my condition to improve, it is up to other people to \n
\n\n"], ["51", "TBI 2ND LEVEL EVAL V2\n", "\n.|.|Comprehensive Traumatic Brain Injury Evaluation||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \nor other items? | <*Answer_3932*>| | 5-D-3. Were you thrown to the ground or against some stationary object like a wall, vehicle or inside a vehicle by the explosion? (This is not asking \nif you "ducked to the ground" to protect yourself).| <*Answer_3933*>| | 5-D-4. Did you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken \nbones, amputations, breathing toxic fumes, or crush injuries from structures falling onto you? | <*Answer_3934*>| | 5-D-5. Type of blast exposures: (Check all that apply)| \n<*Answer_3935*>| | 5-E. Blunt trauma other than from blast/vehicular injury, e.g., assault, blunt force, sports related or object hitting head.| <*Answer_3936*>||6. Did you lose \nconsciousness immediately after any of these experiences?| <*Answer_3937*>| | 6-A. If yes, estimate the duration of longest period of loss of consciousness.| <*Answer_3943*>||7. Did you \nhave a period of disorientation or confusion immediately following the incident?| <*Answer_3944*>| | 7-A. If yes, estimate the duration of longest period of disorientation or confusion.| \n<*Answer_3945*>||8. Did you experience a period of memory loss immediately before or after the incident?| <*Answer_3947*>| | 8-A. If yes, estimate the duration of longest period of memory loss \n(Post Traumatic Amnesia (PTA)).| <*Answer_3956*>||9. During this/these experience(s), did an object penetrate your skull/cranium:| <*Answer_3957*>||10. Were you wearing a helmet at the time of \nmost serious injury?| <*Answer_3958*>||11. Were you evacuated from theatre?| <*Answer_3960*>||12. Prior to this evaluation, had you received any professional treatment (including medications) \nfor your deployment related TBI symptoms?| <*Answer_3961*>| | 12-A. Have you ever been prescribed medications for symptoms related to your deployment related TBI symptoms?| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||A. Was this evaluation furnished by a non-VA provider, e.g., fee basis?| <*Answer_3906*>||1. Current \n<*Answer_3964*>||13. Since the time of your deployment related injury/injuries, has anyone told you that you were acting differently?| <*Answer_3965*>||14. Prior to your OEF/OIF deployment, did \nyou experience a brain injury or concussion?| <*Answer_3969*>||15. Since your OEF/OIF deployment, have you experienced a brain injury or concussion?| <*Answer_3970*>||II. SYMPTOMS||16. \nNeurobehavioral Symptoms:| Please rate the following symptoms with regard to how they have affected you over the past 30 days. Use the following scale:| None 0 - Rarely if ever present; not a \nproblem at all| Mild 1 - Occasionally present, but it does not disrupt activities; I can usually continue what I am doing; does not really concern me.| Moderate 2 - Often present, occasionally \ndisrupts my activities; I can usually continue what I am doing with some effort; I am somewhat concerned.| Severe 3 - Frequently present and disrupts activities; I can only do things that are \nfairly simple or take little effort; I feel like I need help.| Very Severe 4 - Almost always present and I have been unable to perform at work, school, or home due to this problem; I probably cannot \nfunction without help.|| 16-A. Feeling dizzy: <*Answer_3971*>| 16-B. Loss of balance: <*Answer_3988*>| 16-C. Poor coordination, clumsy: <*Answer_3990*>| 16-D. Headaches: \n<*Answer_3991*>| 16-E. Nausea: <*Answer_3992*>| 16-F. Vision problems, blurring, trouble seeing: <*Answer_3993*>| 16-G. Sensitivity to light: <*Answer_3994*>| 16-H. Hearing difficulty: \n <*Answer_3995*>| 16-I. Sensitivity to noise: <*Answer_3996*>| 16-J. Numbness or tingling in parts of my body: <*Answer_3997*>| 16-K. Change in ability to taste and/or smell: \n<*Answer_3998*>| 16-L. Loss of appetite or increase appetite: <*Answer_3999*>| 16-M. Poor concentration, can't pay attention: <*Answer_4000*>| 16-N. Forgetfulness, can't remember things: \nmarital status:| <*Answer_3908*>||2. Pre-military level of educational achievement:| <*Answer_3909*>||3. Current employment status:| <*Answer_3916*>||I. INJURY||4. How many serious OEF/OIF \n<*Answer_4001*>| 16-O. Difficulty making decisions: <*Answer_4002*>| 16-P. Slowed thinking, difficulty getting organized, can't finish things: <*Answer_4003*>| 16-Q. Fatigue, loss of energy, \ngetting tired easily: <*Answer_4007*>| 16-R. Difficulty falling or staying asleep: <*Answer_4008*>| 16-S. Feeling anxious or tense: <*Answer_4009*>| 16-T. Feeling depressed or sad: \n<*Answer_4010*>| 16-U. Irritability, easily annoyed: <*Answer_4011*>| 16-V. Poor frustration tolerance, feeling easily overwhelmed by things: <*Answer_4012*>||17. Overall, in the last 30 days \nhow much did these difficulties (symptoms) interfere with your life?| <*Answer_4013*>| | 17-A. In what areas of your life are you having difficulties because of these symptoms?| \n<*Answer_4014*>||III. PAIN||18. In the last 30 days, have you had any problems with pain?| <*Answer_4017*>| | 18-A. Location of pain: (Check all that apply)| <*Answer_4018*>|| 18-B. In \nthe last 30 days, how much did pain interfere with your life?| <*Answer_4020*>| | 18-C. In what areas of your life are you having difficulties because of pain?| <*Answer_4021*>||19. Since the \ntime of your deployment related injury/injuries, are your overall symptoms:| <*Answer_4023*>||IV. CONCLUSION||20. Additional history of present illness, social history, functional history, patient \ngoals, and other relevant information.| <*Answer_4024*>||21. Current medication:| <*Answer_4025*>||22. Physical Examination:| <*Answer_4026*>||23. Psychiatric Symptoms:| <*Answer_4027*>| \n | 23-A. If yes or suspected/probable, symptoms of which disorders?| <*Answer_4028*>||24. SCI:| <*Answer_4029*>||25. Amputation:| <*Answer_4030*>||26. Other significant medical \nconditions/problems:| <*Answer_4031*>||V. DIAGNOSIS||27. Are the history of the injury and course of clinical symptoms consistent with a diagnosis of TBI sustained during OEF/OIF deployment?| \ndeployment related injuries have occurred?| <*Answer_3917*>| | 4-A-1. Month of most serious injury: <*Answer_3918*>| 4-A-2. Year of most serious injury: <*Answer_3919*>| | 4-B-1. \n<*Answer_4032*>||28. In your clinical judgment the current clinical symptom presentation is most consistent with:| <*Answer_4034*>| | 28-A. Specify other condition(s):| <*Answer_4044*>||VI. \nPLAN||29. Follow up plan:| <*Answer_4045*>|| 29-A. Education:| <*Answer_4046*>|| 29-B. Consult requested with: (Check all that apply)| <*Answer_4047*>|| 29-C. Referral to Polytrauma \nNetwork Site (PNS):| <*Answer_4048*>|| 29-D. Electro diagnostic study (nerve conduction / electromyogram):| <*Answer_4049*>|| 29-D-1. Electroencephalogram (EEG):| <*Answer_4050*>|| \n29-E. Lab:| <*Answer_4051*>|| 29-F. Head CT:| <*Answer_4052*>|| 29-G. Brain MRI:| <*Answer_4053*>|| 29-H. Other Consultation:| <*Answer_4054*>|| 29-I. New medication trial or \nchange in dose of existing medication to address the following symptoms:| <*Answer_4055*>|| 29-I-1. Other symptom(s):| <*Answer_4086*>||30. Details of Plan:| <*Answer_4087*>||Information \ncontained 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 \nwith other |diagnostic activities and procedures.| | $~\nMonth of second serious injury: <*Answer_3920*>| 4-B-2. Year of second serious injury: <*Answer_3921*>| | 4-C-1. Month of least serious injury: <*Answer_3922*>| 4-C-2. Year of least \nserious injury: <*Answer_3923*>||5. Cause of Injury:| 5-A. Bullet: <*Answer_3924*>| | 5-B. Vehicular: <*Answer_3925*>| | 5-C. Fall: <*Answer_3926*>| | 5-D. Blast: \n<*Answer_3927*>| | 5-D-1. When a high-explosive bomb or IED goes off there is a "blast wave" which is a wave of highly compressed gas that may feel almost like being smashed into a wall. Do \nyou remember experiencing this or were told that you experienced it? | <*Answer_3928*>| | 5-D-1-a. Estimated distance from closest blast: <*Answer_3929*>| | 5-D-2. This \n"blast wave" is followed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough to the blast to be "peppered" or hit by such debris, shrapnel, \n
\n\n"], ["52", "COMP TBI EVAL\n", "\n_|MHRRTP Veteran Satisfaction Survey||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5255*>|15. Veterans' activities are carefully planned.| <*Answer_5256*>|16. If a veteran breaks a rule, s/he knows what the consequences will be.| <*Answer_5257*>|17. Once a schedule \nis arranged for a veteran, the veteran must follow it.| <*Answer_5258*>|18. This is a lively place.| <*Answer_5259*>|19. Staff have relatively little time to encourage veterans.| \n<*Answer_5260*>|20. Veterans say anything they want to the staff.| <*Answer_5261*>|21. Veterans can leave here anytime without saying where they are going.| <*Answer_5262*>|22. There is \nrelatively little emphasis on teaching veterans solutions to practical problems.| <*Answer_5263*>|23. Personal problems are openly talked about.| <*Answer_5264*>|24. This is a very well \norganized program.| <*Answer_5265*>|25. If a veteran's program is changed, staff always tell him/her why.| <*Answer_5266*>|26. The staff very rarely punish veterans by taking away their \nprivileges.| <*Answer_5267*>|27. The veterans are proud of this program.| <*Answer_5268*>|28. Veterans seldom help each other.| <*Answer_5269*>|29. It is hard to tell how veterans are \nfeeling here.| <*Answer_5270*>|30. Veterans are expected to take leadership here.| <*Answer_5271*>|31. Veterans are expected to make detailed, specific plans for the future.| \n<*Answer_5272*>|32. Veterans are rarely asked personal questions by the staff.| <*Answer_5273*>|33. The staff make sure that this place is always neat.| <*Answer_5274*>|34. Staff rarely give \nveterans a detailed explanation of what the program is about.| <*Answer_5275*>|35. Veterans who break the rules are penalized for it.| <*Answer_5276*>|36. There is very little group spirit in \nthis program.| <*Answer_5277*>|37. Staff are very interested in following up with veterans once they leave the program.| <*Answer_5278*>|38. Veterans are careful about what they say when staff \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||||A. Date of admission to this MHRRTP (mm/dd/yyyy):| <*Answer_5474*>|B. MHRRTP Type:| <*Answer_5350*>|1. What race do you \nare around.| <*Answer_5279*>|39. The staff tend to discourage criticism from veterans.| <*Answer_5280*>|40. There is relatively little discussion about exactly what veterans will be doing after \nthey leave the program.| <*Answer_5281*>|41. Veterans are expected to share their personal problems with each other.| <*Answer_5282*>|42. This place usually looks a little messy.| \n<*Answer_5283*>|43. The program rules are clearly understood by the veterans.| <*Answer_5284*>|44. If a veteran fights with another veteran, s/he will get into real trouble with the staff.| \n<*Answer_5285*>|45. Staff welcome me and help me feel comfortable in this program.| <*Answer_5286*>|46. The physical space of this program (for example, the lobby and/or waiting rooms) feels \ninviting and dignified.| <*Answer_5287*>|47. Staff regularly asks me about my interests and the things I would like to do in the community.| <*Answer_5288*>|48. I can easily access my treatment \nrecords if I want to.| <*Answer_5289*>|49. Staff introduces me to veterans in recovery who can serve as role models or mentors.| <*Answer_5290*>|50. I am/can be involved with staff trainings \nand education programs at this VA.| <*Answer_5291*>|51. Staff helps me to develop and plan for life goals beyond managing symptoms or staying stable (for example, employment, education, physical \nfitness, connecting with family and friends, hobbies).| <*Answer_5292*>|52. This program offers specific services that fit my unique culture and life experiences.| <*Answer_5293*>|53. Staff \nlistens to me and respects my decisions about my treatment and care.| <*Answer_5294*>|54. Staff offers to help me connect with self-help, peer support, or consumer advocacy groups and programs.| \n <*Answer_5295*>|55. I am encouraged to attend VA advisory boards and/or management meetings if I want.| <*Answer_5296*>|56. Staff helps me to find jobs.| <*Answer_5297*>|57. Staff listens, and \nconsider yourself?| <*Answer_5404*>|1-A. Are you Hispanic, Spanish or Latino?| <*Answer_5405*>|2. How many years of education have you completed?| <*Answer_5402*>|3. Have you ever been \nresponds, to my cultural experiences, interests, and concerns| <*Answer_5298*>|58. Staff does not use threats, bribes, or other forms of pressure to get me to do what they want.| \n<*Answer_5299*>|59. Staff talks with me about what it would take to complete or exit this program.| <*Answer_5300*>|60. I am encouraged to help staff with the development of new groups, programs, \nor services.| <*Answer_5301*>|61. Staff works hard to help me fulfill my personal goals.| <*Answer_5302*>|62. In the last MONTH, how often did you participate in an activity where you felt \ncompletely involved in what you were doing, so much so that you lost track of time?| <*Answer_5303*>|63. In the last MONTH, how often did you participate in an activity where you felt you learned \nsomething important about yourself?| <*Answer_5304*>|64. In the last MONTH, how often did you participate in an activity where you had a sense of accomplishment or felt proud of what you had \ndone?| <*Answer_5305*>|65. In the last MONTH, how often did you participate in an activity where you felt that your life has purpose or meaning?| <*Answer_5306*>|66. In the last MONTH, how \noften did you participate in an activity where you experienced yourself growing as a person?| <*Answer_5307*>|67-A. I find strength and comfort in my spirituality.| <*Answer_5308*>|67-B. I feel \ndeep inner peace or harmony.| <*Answer_5309*>|67-C. I feel a spiritual presence.| <*Answer_5310*>|68. How do you feel about your life as a whole?| <*Answer_5311*>|69. Thinking ahead to \ntwelve months from today, do you expect your mental health will be:| <*Answer_5312*>|70. How much do you feel you know about your mental health problems, including symptoms and types of treatment, \nsuch as medication, and rehabilitation?| <*Answer_5313*>|71. How much input do you have into your treatment and/or rehabilitation plan?| <*Answer_5314*>|72. Overall, how would you rate the \nhomeless since leaving military service?| <*Answer_5477*>|4. Were you homeless when you last lived in the community (before this current VA admission)?| <*Answer_5476*>|5. Did you transfer to \nquality of care you receive in this program?| <*Answer_5315*>|73. Overall, how satisfied are you with the care you receive in this program?| <*Answer_5316*>|74. Would you recommend this program \nto other veterans if they needed care?| <*Answer_5317*>|75. If you could have free care outside of the VA, would you choose to come to this program again?| <*Answer_5318*>|76-A. Alcoholics \nAnonymous (AA)?| <*Answer_5478*>|76-B. Narcotics Anonymous (NA)?| <*Answer_5479*>|76-C. Al-Anon?| <*Answer_5480*>|76-D. Peer support-groups for veterans (for example, Vet-to-Vet)?| \n<*Answer_5481*>| $~\nthis program from another VA inpatient unit or VA residential program?| <*Answer_5475*>|6. In general, at the present time would you say your physical health is:| <*Answer_5243*>|7. In general, \nat the present time would you say your mental health is:| <*Answer_5244*>|8. Do you take any prescription medications on a regular basis?| <*Answer_5245*>|8-A. Do you receive any of your \nmedications from a nurse?| <*Answer_5247*>|8-B. Do you receive any of your medications from the VA pharmacy?| <*Answer_5248*>|9. Veterans put a lot of energy into what they do around here.| \n<*Answer_5250*>|10. The healthier veterans here take care of the less healthy ones.| <*Answer_5251*>|11. Veterans tend to hide their feelings from one another.| <*Answer_5252*>|12. There is no \nveteran leadership in this program.| <*Answer_5253*>|13. This program emphasizes training for new kinds of jobs.| <*Answer_5254*>|14. Veterans hardly ever discuss their sexual lives.| \n
\n\n"], ["53", "MHRRTP SATISFACTION SURVEY\n", "\n.|.|VA SAT Monitoring Instrument||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n2,3,4), Percocet, Vicodin, Fentanyl, etc.)| <*Answer_5489*>| 7F. Other Drugs (Steroids, non-prescription sleep/diet pills, Benadryl, Ephedra, other over-the-counter medications, etc.)| \n<*Answer_5490*>| 7G. Inhalants (glues/adhesives, nail polish remover, paint thinner)| <*Answer_5491*>||8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or \nuse drugs?| <*Answer_5338*>|9. How confident are you in your ability to be completely abstinent (clean) from alcohol and drugs in the next 30 days?| <*Answer_5339*>|10. In the past 30 days, how \nmany days did you attend self-help meetings like AA or NA to support your recovery?| <*Answer_5340*>|11. In the past 30 days, how many days were you in any situations or with any people that might \nput you at an increased risk for using alcohol or drugs? (i.e., around risky people, places, or things)| <*Answer_5341*>|12. Does your religion or spirituality help support your recovery?| \n<*Answer_5342*>|13. In the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?| <*Answer_5343*>|14. Do you have enough income (from legal sources) \nto pay for necessities, such as housing, transportation, food and clothing for yourself and your dependents?| <*Answer_5344*>|15. In the past 30 days, how much have you been bothered by arguments \nor problems getting along with any family members or friends?| <*Answer_5345*>|16. In the past 30 days, how many days have you spent time with any family members or friends who are supportive of \nyour recovery?| <*Answer_5346*>|17. How satisfied are you with your progress toward achieving your recovery goals?| <*Answer_5347*>| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||A. Today's Date:| <*Answer_5329*>|B. Method of Administration:| <*Answer_5330*>||1. In the past 30 days, how would you \nsay your physical health has been?| <*Answer_5331*>|2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?| <*Answer_5332*>|3. In the past 30 days, how \nmany days have you felt depressed, anxious, angry, or very upset throughout most of the day?| <*Answer_5333*>|4. In the past 30 days, how many days did you drink ANY alcohol?| \n<*Answer_5334*>|5. 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 \noz.) or a 12-ounce can/bottle of beer or 5 ounce glass of wine.) | <*Answer_5335*>|6. In the past 30 days, how many days did you use any illegal/street drugs or abuse any precription \nmedications?| <*Answer_5336*>||7. In the past 30 days, how many days did you use any of the following substaces?|| 7A. Marijuana (weed, pot, cannabis)| <*Answer_5485*>| 7B. \nSedatives/Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, "barbs" Phenobarbitol, downers, etc.)| <*Answer_5486*>| 7C. Cocaine/Crack| <*Answer_5487*>| 7D. Other Stimulants \n(amphetamine, methamphetamine, Dexadrine, Ritalin, Adderall, "speed", "crystal meth", etc.)| <*Answer_5488*>| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, codeine (Tylenol \n
\n\n"], ["54", "SBE\n", "\n.|.|Index of Activities of Daily Living||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Date of Evaluation:| <*Answer_5406*>|1. Bathing: either sponge bath, tub bath or shower.| <*Answer_5407*>|2. Dressing: \ngets clothes from closets and drawers, including under-clothes, outer garmets and using fasteners (including braces if worn).| <*Answer_5408*>|3. Toileting: going to the "toilet room" for bowel \nand urine elimination; cleaning self after elimination and arranging clothes.| <*Answer_5409*>|4. Transfer:| <*Answer_5410*>|5. Continence:| <*Answer_5411*>|6. Feeding:| <*Answer_5412*>| \n $~\n
\n\n"], ["55", "KATZ-ADL-18PT\n", "\n.|.|Katz Index of Independence in Activities of Daily Living-18pt||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Katz Index of Independence in ADL: <-Independence->||Index score possible range is 6 to 18. A high index indicates independence, a low index \nmeans dependence on others to help with activities of daily living.||Questions and Answers||1.Bathing: either sponge bath, tub bath or shower.| <*Answer_5132*>|2.Dressing: gets clothes from \nclosets and drawers, including under-clothes, outer garments and using fasteners (including braces if worn).| <*Answer_5133*>|3.Toileting: going to the "toilet room" for bowel and urine \nelimination; cleaning self after elimination and arranging clothes. (May use cane, walker, or wheelchair, and manage bedpan or commode, emptying same next morning). | <*Answer_5134*>|4.Transfer:| \n <*Answer_5135*>|5.Continence:| <*Answer_5136*>|6.Feeding:| <*Answer_5137*>|||Sources:|Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. \n1970;10(1):20-30.|Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The Index of ADL: a standardized measure of biological and psychosocial function. JAMA. \n1963;185(12):914-9. $~\n
\n\n"], ["56", "CIWA-AR\n", "\n.|.|Clinical Institute Withdrawal Assessment - Alcohol Revised||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<*Answer_4874*>|11. HEADACHE, FULLNESS IN HEAD - Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, \nrate severity:| <*Answer_4875*>|12. AGITATION - Observation:| <*Answer_4876*>|13. ORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who am I?"| \n<*Answer_4877*>|||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 \naccuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||CIWA-AR| Total Score: <-Total Score->||Scores of less than 8 to 10 indicate minimal to mild withdrawal. \n|Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal).|Scores of 15 or more indicate severe withdrawal (impending delirium tremens). ||Questions and Answers||1. Time (use 24 hour \nclock, midnight is 00:00):| <*Answer_4865*>|2. Pulse or heart rate (taken for one minute):| <*Answer_4866*>|3. Blood pressure:| <*Answer_4867*>|4. NAUSEA AND VOMITING - Ask, "Do you feel \nsick to your stomach? Have you vomited?" Observation:| <*Answer_4868*>|5. TACTILE DISTURBANCES - Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel \nbugs crawling on or under your skin?" Observation:| <*Answer_4869*>|6. TREMOR - Arms extended and fingers spread apart. Observation:| <*Answer_4870*>|7. AUDITORY DISTURBANCES - Ask, "Are you \nmore aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation: | \n<*Answer_4871*>|8. PAROXYSMAL SWEATS - Observation:| <*Answer_4872*>|9. VISUAL DISTURBANCES - Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you \nseeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation: | <*Answer_4873*>|10. ANXIETY - Ask, "Do you feel nervous?" Observation:| \n
\n\n"], ["57", "ZBI SHORT\n", "\n.|.|Zarit Burden Interview: Short version||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||ZBI Short Version Score: <-Score->| A score of 17 or higher reflects a high burden and needs follow up. ||Questions and \nAnswers||1. Do you feel that because of the time you spend with your relative that you dont have enough time for yourself?| <*Answer_5260*>|2. Do you feel stressed between caring for your relative \nand trying to meet other responsibilities (work/family)?| <*Answer_5261*>|3. Do you feel angry when you are around your relative?| <*Answer_5262*>|4. Do you feel that your relative currently \naffects your relationship with family members or friends in a negative way?| <*Answer_5263*>|5. Do you feel strained when you are around your relative?| <*Answer_5264*>|6. Do you feel that your \nhealth has suffered because of your involvement with your relative?| <*Answer_5265*>|7. Do you feel that you dont have as much privacy as you would like because of your relative?| \n<*Answer_5266*>|8. Do you feel that your social life has suffered because you are caring for your relative?| <*Answer_5267*>|9. Do you feel that you have lost control of your life since your \nrelatives illness?| <*Answer_5268*>|10. Do you feel uncertain about what to do about your relative?| <*Answer_5269*>|11. Do you feel you should be doing more for your relative?| \n<*Answer_5270*>|12. Do you feel you could do a better job in caring for your relative?| <*Answer_5271*>||Copyright (c) 1983 Steven Zarit $~\n
\n\n"], ["58", "ZBI SCREEN\n", "\n.|.|Zarit Burden Interview: Screening version||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||ZBI Screening Score: <-Score->| A score of 8 or higher reflects a high burden and needs follow up.||Questions and Answers||1. \nDo you feel that because of the time you spend with your relative that you dont have enough time for yourself?| <*Answer_5224*>|2. Do you feel stressed between caring for your relative and trying \nto meet other responsibilities (work/family)?| <*Answer_5257*>|3. Do you feel strained when you are around your relative?| <*Answer_5258*>|4. Do you feel uncertain about what to do about your \nrelative?| <*Answer_5259*>||Copyright (c) 1983 Steven Zarit$~\n
\n\n"], ["6", "ASSIST-WHOV3\n", "\n.|.|The Alcohol, Smoking and Substance Involvement Test||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \nmethadone, 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. \nTobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_3965*>| 2b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3969*>| 2c. Cannabis (marijuana, pot, grass, hash, \netc.)| <*Answer_3970*>| 2d. Cocaine (coke, crack, etc.)| <*Answer_3971*>| 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3988*>| 2f. Inhalants (nitrous, glue, \npetrol, paint thinner, etc.)| <*Answer_3990*>| 2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3991*>| 2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, \netc.)| <*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 \noften 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, \netc.)| <*Answer_3996*>| 3c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3997*>| 3d. Cocaine (coke, crack, etc.)| <*Answer_3998*>| 3e. Amphetamine type stimulants (speed, diet \npills, ecstasy, etc.)| <*Answer_3999*>| 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4000*>| 3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| \n<*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 \nspecified 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 \n<.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: \nproducts (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4008*>| 4b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4009*>| 4c. Cannabis (marijuana, pot, grass, hash, etc.)| \n<*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, \npaint thinner, etc.)| <*Answer_4013*>| 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4014*>| 4h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| \n<*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 \nyou 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, \netc.)| <*Answer_4023*>| 5c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4024*>| 5d. Cocaine (coke, crack, etc.)| <*Answer_4025*>| 5e. Amphetamine type stimulants (speed, diet \npills, ecstasy, etc.)| <*Answer_4026*>| 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4027*>| 5g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| \n<*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 \nprevious 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, \nchewing tobacco, cigars, etc.)| <*Answer_4032*>| 6b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4034*>| 6c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_4044*>| 6d. \n<-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+ \nCocaine (coke, crack, etc.)| <*Answer_4045*>| 6e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_4046*>| 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| \n<*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 \n(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 \nDRUG, SECOND DRUG, ETC.)?| 7a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)| <*Answer_4052*>| 7b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_4053*>| 7c. Cannabis \n(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*>| \n7f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_4087*>| 7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_4088*>| 7h. Hallucinogens (LSD, acid, \nmushrooms, PCP, Special K, etc.)| <*Answer_4089*>| 7i. Opioids (heroin, morphine, methadone, codeine, etc.)| <*Answer_4090*>| 7j. Other (as previously specified)| <*Answer_4189*>||8. Have \nyou 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 \nself-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 \nprocedures.| $~\nHigh| 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, \n4-26 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-> \n0-3 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, \netc.)| <*Answer_3934*>| 1b. Alcoholic beverages (beer, wine, spirits, etc.)| <*Answer_3935*>| 1c. Cannabis (marijuana, pot, grass, hash, etc.)| <*Answer_3936*>| 1d. Cocaine (coke, crack, \netc.)| <*Answer_3937*>| 1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)| <*Answer_3945*>| 1f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)| <*Answer_3956*>| 1g. \nSedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)| <*Answer_3957*>| 1h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)| <*Answer_3958*>| 1i. Opioids (heroin, morphine, \n
\n\n"], ["60", "VA SAT MONITOR\n", "\n.|.|Suicide Behavior Event ||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||||1. Date of suicide event:| <*Answer_5361*>|2. Time of suicide event:| <*Answer_5362*>|3. Accuracy of Date and Time of \nsuicide event:| <*Answer_5363*>|4. Location of suicide event:| <*Answer_5364*>|5. Patient status at time of suicide event?| <*Answer_5365*>|5a. Inpatient Unit:| <*Answer_5368*>|5b. \nInpatient status at time of suicide event:| <*Answer_5369*>|6. Outcome of suicide event?| <*Answer_5366*>|6a. Hospital:| <*Answer_5367*>|7. Primary source of information:| \n<*Answer_5370*>|7a. Name and phone number| <*Answer_5371*>|8. Type of contact with primary source:| <*Answer_5372*>|9. Patient stated their intention to commit suicide was: (Ask: What did you \nthink the outcome would be?)| <*Answer_5373*>|10. Staff evaluation of patient's intention to commit suicide:| <*Answer_5374*>|11. Staff evaluation of the lethality of patient's plan to commit \nsuicide:| <*Answer_5375*>|12. Does the patient have access to firearms?| <*Answer_5376*>|13. Description of suicide event:| <*Answer_5377*>|14. Patient is currently receiving treatment in \nthese areas (check all that apply):| <*Answer_5378*>|14a. Specialty Care:| <*Answer_5379*>|15. Primary care provider:| <*Answer_5381*>|16. Case manager / therapist:| <*Answer_5382*>|17. \nProvider prescribing psychiatric medication:| <*Answer_5383*>|18. Brief plan and / or disposition (check all that apply):| <*Answer_5384*>|18a. Other:| <*Answer_5385*>| $~\n
\n\n"], ["61", "CESD5\n", "\n|Center for Epidemiologic Studies Depression Scale (5-item version)||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||CESD5 Scale Score: ||Questions and Answers|1.I felt that I could not shake off the blues even with help \nfrom my family or friends.| <*Answer_3821*>|2.I felt depressed.| <*Answer_3822*>|3.I felt hopeful about the future.| <*Answer_3825*>|4.I felt fearful.| <*Answer_3823*>|5.My sleep was \nrestless.| <*Answer_3824*>| $~\n
\n\n"], ["62", "KATZ ADL\n", "\n.|.|Katz Index of Independence in Activities of Daily Living||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: \n<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||<.DLL_String.>||Questions and Answers||1. Bathing:| <*Answer_5421*>|2. Dressing:| <*Answer_5422*>|3. \nToileting:| <*Answer_5423*>|4. Transferring:| <*Answer_5424*>|5. Continence:| <*Answer_5425*>|6. Feeding:| <*Answer_5426*>|||Information contained in this note is based on a self-report \nassessment 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 \nprocedures.||Copyright (c) The Gerontological Society of America.| $~\n
\n\n"], ["63", "SBR\n", "\n.|.|Suicide Behavior Report||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \ntreatment at time of this event (if none, type "None"):| <*Answer_5196*>| 16B.Primary Care Provider:| <*Answer_5448*>| 16C.Case Manager / Therapist:| <*Answer_5352*>| 16D.Provider \nprescribing psychiatric medications:| <*Answer_5353*>|17.Active Problem List:| <*Answer_5449*>|18.Inpatient Unit at time of event:| <*Answer_5348*>| 18A.Inpatient status at time of event:| \n <*Answer_5349*>|19.Brief Plan or Disposition (Check all that apply):| <*Answer_5197*>| 19A.Any other plan or disposition not list above? (If none, type "None")| <*Answer_5198*>|||Information \ncontained 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 \nwith other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||Questions and Answers||1.Is there any indication the Veteran engaged in self-directed violent behavior?| \n<*Answer_5339*>|2.Is or was there evidence of Suicidal Intent?| <*Answer_5340*>|3.Did the behavior involve any injury?| <*Answer_5341*>| 3A.Select the most appropriate SDV behavior from this \nlist:| <*Answer_5342*>| 3B.Select the most appropriate SDV behavior from this list:| <*Answer_5343*>|4.Date and Time of event:| <*Answer_5178*>|5.Brief description of event:| \n<*Answer_5194*>|6.Location of event:| <*Answer_5180*>|7.Patient status at time of event:| <*Answer_5181*>|8.Veteran status following the event:| <*Answer_5344*>| 8A.Hospitalized at:| \n<*Answer_5182*>|9.Method of information:| <*Answer_5186*>|10.Source of information:| <*Answer_5187*>| 10A.Specify "Other":| <*Answer_5188*>| 10B.Name and phone of source:| \n<*Answer_5189*>|11.Last Pain Score:| <*Answer_5446*>|12.Did the patient have access to firearms?| <*Answer_5193*>|13.Family and other supports available at time of the event:| \n<*Answer_5345*>| 13A.Other support:| <*Answer_5346*>|14.Treatment plan changes implemented due to the event:| <*Answer_5347*>| 14A.Describe/Other:| <*Answer_5356*>|15.Past 10 clinic \nvisits:| <*Answer_5447*>|16.Patient was receiving treatment in the following area(s) at the time of this event:| <*Answer_5195*>| 16A.Name any specialty clinic(s) patient was receiving \n
\n\n"], ["65", "PHQ-15\n", "\n.| .| Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | PHQ-15 Score: <-PHQ-15 Score->| | Minimal 0-4| Low \n5-9| Medium 10-14| High 15-30| | | Questions and Answers| | a. Stomach pain| <*Answer_5191*>| b. Back pain| <*Answer_5192*>| c. Pain in your arms, legs, or joints (knees, hips, \netc.)| <*Answer_5297*>| d. Menstrual cramps or other problems with your periods [Women only]| <*Answer_5298*>| e. Headaches| <*Answer_5299*>| f. Chest pain| <*Answer_5300*>| g. \nDizziness| <*Answer_5301*>| h. Fainting spells| <*Answer_5302*>| i. Feeling your heart pound or race| <*Answer_5303*>| j. Shortness of breath| <*Answer_5304*>| k. Pain or problems \nduring sexual intercourse| <*Answer_5305*>| l. Constipation, loose bowels, or diarrhea| <*Answer_5306*>| m. Nausea, gas, or indigestion| <*Answer_5307*>| n. Feeling tired or having low \nenergy| <*Answer_5308*>| o. Trouble sleeping| <*Answer_5400*>| | Copyright (c) 1999 Pfizer Inc. All rights reserved. Reproduced with permission.| | Information contained in this note is \nbased 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 \nactivities and procedures.| $~\n
\n\n"], ["66", "AAQ-2\n", "\n .| .| The Acceptance and Action Questionnaire (AAQ-2)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n SSN: 66,<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | AAQ-2 Score: <-AAQ-2 Score->| High scores on the AAQ-2 indicate psychological \nflexibility (range: 10 to 70).| | | Questions and Answers| | 1. It's OK if I remember something unpleasant.| <*Answer_5450*>| 2. My painful experiences and memories make it \ndifficult for me to live a life that I would value.| <*Answer_5451*>| 3. I'm afraid of my feelings.| <*Answer_5452*>| 4. I worry about not being able to control my worries and \nfeelings.| <*Answer_5461*>| 5. My painful memories prevent me from having a fulfilling life.| <*Answer_5462*>| 6. I am in control of my life.| <*Answer_5463*>| 7. Emotions \ncause problems in my life.| <*Answer_5464*>| 8. It seems like most people are handling their lives better than I am.| <*Answer_5465*>| 9. Worries get in the way of my success.| \n<*Answer_5466*>| 10. My thoughts and feelings do not get in the way of how I want to live my life.| <*Answer_5467*>| | | Information contained in this note is based on a self-report \nassessment 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.| \n $~\n
\n\n"], ["67", "FFMQ\n", "\n.| .| Five Facet Mindfulness Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nattention to sensations, such as the wind in my hair or sun on my face.| <*Answer_5482*>| 16. I have trouble thinking of the right words to express how I feel about things.| <*Answer_5483*>| \n17. I make judgments about whether my thoughts are good or bad.| <*Answer_5484*>| 18. I find it difficult to stay focused on what's happening in the present.| <*Answer_5485*>| 19. When I have \ndistressing thoughts or images, I "step back" and am aware of the thought or image without getting taken over by it.| <*Answer_5486*>| 20. I pay attention to sounds, such as clocks ticking, birds \nchirping, or cars passing.| <*Answer_5487*>| 21. In difficult situations, I can pause without immediately reacting.| <*Answer_5488*>| 22. When I have a sensation in my body, it's difficult \nfor me to describe it because I can't find the right words.| <*Answer_5489*>| 23. It seems I am "running on automatic" without much awareness of what I'm doing.| <*Answer_5490*>| 24. When I \nhave distressing thoughts or images, I feel calm soon after.| <*Answer_5491*>| 25. I tell myself that I shouldn't be thinking the way I'm thinking.| <*Answer_5492*>| 26. I notice the smells \nand aromas of things.| <*Answer_5493*>| 27. Even when I'm feeling terribly upset, I can find a way to put it into words.| <*Answer_5494*>| 28. I rush through activities without being really \nattentive to them.| <*Answer_5495*>| 29. When I have distressing thoughts or images I am able just to notice them without reacting.| <*Answer_5496*>| 30. I think some of my emotions are bad \nor inappropriate and I shouldn't feel them.| <*Answer_5497*>| 31. I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow.| \n<*Answer_5498*>| 32. My natural tendency is to put my experiences into words.| <*Answer_5499*>| 33. When I have distressing thoughts or images, I just notice them and let them go.| \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Mindfulness Scales| | Observe: <-Observe->| Describe: <-Describe->| Act With Awareness: <-ActWithAwareness->| \n<*Answer_5500*>| 34. I do jobs or tasks automatically without being aware of what I'm doing.| <*Answer_5501*>| 35. When I have distressing thoughts or images, I judge myself as good or bad, \ndepending what the thought/image is about.| <*Answer_5502*>| 36. I pay attention to how my emotions affect my thoughts and behavior.| <*Answer_5503*>| 37. I can usually describe how I feel at \nthe moment in considerable detail.| <*Answer_5504*>| 38. I find myself doing things without paying attention.| <*Answer_5505*>| 39. I disapprove of myself when I have irrational ideas.| \n<*Answer_5506*>| | $~\nNonjudge: <-Nonjudge->| Nonreact: <-Nonreact->| | Questions and Answers| | 1. When I'm walking, I deliberately notice the sensations of my body moving.| <*Answer_5468*>| 2. I'm good at finding \nwords to describe my feelings.| <*Answer_5469*>| 3. I criticize myself for having irrational or inappropriate emotions.| <*Answer_5470*>| 4. I perceive my feelings and emotions without having \nto react to them.| <*Answer_5471*>| 5. When I do things, my mind wanders off and I'm easily distracted.| <*Answer_5472*>| 6. When I take a shower or bath, I stay alert to the sensations of \nwater on my body.| <*Answer_5473*>| 7. I can easily put my beliefs, opinions, and expectations into words.| <*Answer_5474*>| 8. I don't pay attention to what I'm doing because I'm \ndaydreaming, worrying, or otherwise distracted.| <*Answer_5475*>| 9. I watch my feelings without getting lost in them.| <*Answer_5476*>| 10. I tell myself I shouldn't be feeling the way I'm \nfeeling.| <*Answer_5477*>| 11. I notice how foods and drinks affect my thoughts, bodily sensations, and emotions.| <*Answer_5478*>| 12. It's hard for me to find the words to describe what I'm \nthinking.| <*Answer_5479*>| 13. I am easily distracted.| <*Answer_5480*>| 14. I believe some of my thoughts are abnormal or bad and I shouldn't think that way.| <*Answer_5481*>| 15. I pay \n
\n\n"], ["69", "GAI\n", "\n.|.|Geriatric Anxiety Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5525*>|20.I often feel upset.| <*Answer_5526*>||Copyright (c) 2010 The University of Queensland| |Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||GAI Score: <-GAI Score->|| Score Interpretation of Score| ----- -----------------------| \n 0-8 Absence of clinically significant anxiety| 9 and above Presence of clinically significant anxiety\n||Questions and Answers||1.I worry a lot of the time.| <*Answer_5507*>|2.I find it difficult to make a decision.| <*Answer_5508*>|3.I often feel jumpy.| <*Answer_5509*>|4.I find it \nhard to relax.| <*Answer_5510*>|5.I often cannot enjoy things because of my worries.| <*Answer_5511*>|6.Little things bother me a lot.| <*Answer_5512*>|7.I often feel like I have butterflies \nin my stomach.| <*Answer_5513*>|8.I think of myself as a worrier.| <*Answer_5514*>|9.I can't help worrying about even trivial things.| <*Answer_5515*>|10.I often feel nervous.| \n<*Answer_5516*>|11.My own thoughts often make me anxious.| <*Answer_5517*>|12.I get an upset stomach due to my worrying.| <*Answer_5518*>|13.I think of myself as a nervous person.| \n<*Answer_5519*>|14.I always anticipate the worst will happen.| <*Answer_5520*>|15.I often feel shaky inside.| <*Answer_5521*>|16.I think that my worries interfere with my life.| \n<*Answer_5522*>|17.My worries often overwhelm me.| <*Answer_5523*>|18.I sometimes feel a great knot in my stomach.| <*Answer_5524*>|19.I miss out on things because I worry too much.| \n
\n\n"], ["7", "File: 601.71, IEN: 100108\n", "\n WHYMPI Date Given: <.Date Given.> Clinician: <.Staff: Ordered By.> Location: <.Location.> Veteran: <.Patient Name: Last, First.> SSN: <.Patient: SSN.> DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>) Gender: <.Patient: Gender.> This is a sample report to help you get started. Use the right button of the mouse to display editing options (these also appear in the "Tools"menu and the Navigation panel). Instructions appear in the lower panel and change depending upon the location of the mouse. You will need to delete this paragraph later. <_Script_1_> $~ <_Script_1_>=Please indicate who your significant other is:`101620`6. Parent/Child/Other relative`100984`Equals``````Script for q1, ans 6.~\n
\n\n"], ["70", "GPCOG\n", "\n.| .| General Practitioner Assessment of Cognition| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | GPCOG Score: <-GPCOG Score->| | Low scores indicate cognitive impairment, range 0 to 9.| 9 \n No significant cognitive impairment and further testing not necessary.| 5-8 More information required.| 0-4 Cognitive impairment is indicated.| | Questions and Answers| | 1. What is \nthe date? (Answer must be exact.)| <*Answer_5527*>| 2. Please draw a clock on the paper provided. Mark in all the numbers to indicate the hours of a clock (Correct: the numbers 12, 3, 6, and 9 \nshould be in the correct quadrants of the circle and the other numbers should be approximately correctly placed.) | <*Answer_5528*>| 3. Please mark in hands to show 10 minutes past eleven \no'clock, 11:10. (Correct: the hands should be pointing to the 11 and the 2, but do not penalize if the respondent fails to distinguish the long and short hands.) | <*Answer_5529*>| 4. Can you \ntell me something that happened in the news recently? (Correct: Must be in the last week. Extensive details are not required but a general answer without details, e.g., war, lots of rain, after \nprodding, is incorrect.) | <*Answer_5530*>| 5. Recall items| 5A. John| <*Answer_5531*>| 5B. Brown| <*Answer_5532*>| 5C. 42| <*Answer_5533*>| 5D. West (Street)| \n<*Answer_5534*>| 5E. Kensington| <*Answer_5535*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \n
\n\n"], ["71", "IADL\n", "\n.| .| Lawton-Brody Instrumental Activities of Daily Living Scale (IADL)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | IADL Scale: <-IADL Scale->| A low score indicates dependence on \nothers to help with daily activities. A high score indicates independent living. Range is 0 to 8.| | | Questions and Answers| | 1. Ability to use telephone| <*Answer_4864*>| 2. Shopping| \n<*Answer_5131*>| 3. Food Preparation| <*Answer_5177*>| 4. Housekeeping| <*Answer_5179*>| 5. Laundry| <*Answer_5183*>| 6. Mode of Transportation| <*Answer_5184*>| 7. \nResponsibility for own medications| <*Answer_5185*>| 8. Ability to Handle Finances| <*Answer_5190*>| | Copyright (c) The Gerontological Society of America.| | Information contained in this \nnote 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 \nactivities and procedures.| $~\n
\n\n"], ["72", "MINICOG\n", "\n| Mini-Cog Test\n| Gender: <.Patient_Gender.>\n| \n| <*Answer_7771*>\n| \n| A cut point of <3 on the Mini-Cog(tm) has been validated for dementia\n| screening, but many individuals with clinically meaningful cognitive\n| impairment will score higher. When greater sensitivity is desired, a\n| cut point of <4 is recommended as it may indicate a need for further\n| evaluation of cognitive status.\n| \n| \n| \n| Questions and Answers\n|\n<*Answer_7772*>\n| \n| Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic\n purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures\n| Date Given: <.Date_Given.>\n| Clinician: <.Staff_Ordered_By.>\n| Location: <.Location.>\n| \n| Veteran: <.Patient_Name_Last_First.>\n| SSN: <.Patient_SSN.>\n| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\n
\n\n"], ["75", "MOCA\n", "\n.| .| Montreal Cognitive Assessment| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \nresponse for the backwards trial is 2-4-7.| <*Answer_5549*>| 5C. Vigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).| \n <*Answer_5550*>| 5D. Serial 7s starting at 100. Continue for five responses.| <*Answer_5551*>| 6. Sentence repetition| 6A. I only know that John is the one to help today.| \n<*Answer_5552*>| 6B. The cat always hid under the couch when dogs were in the room.| <*Answer_5553*>| 7. Words beginning with the letter F.| <*Answer_5554*>| 8. Abstraction| 8A. \nSimilarity between TRAIN - BICYCLE.| <*Answer_5555*>| 8B. Similarity between WATCH - RULER.| <*Answer_5556*>| 9. Delayed recall| 9A. Recall FACE| <*Answer_5557*>| 9B. \nRecall VELVET.| <*Answer_5558*>| 9C. Recall CHURCH.| <*Answer_5559*>| 9D. Recall DAISY.| <*Answer_5560*>| 9E. Recall RED.| <*Answer_5561*>| 10. Orientation| 10A. \nToday's date,| <*Answer_5562*>| 10B. Current month| <*Answer_5563*>| 10C. Current year| <*Answer_5564*>| 10D. Day of the week| <*Answer_5565*>| 10E. What place is \nthis?| <*Answer_5566*>| 10F. What city are we in?| <*Answer_5567*>| 11. Years of formal education:| <*Answer_5568*>| | Copyright (c) Z. Nasreddine MD| | Information contained \nin 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 \ndiagnostic activities and procedures.| $~\nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | MoCA Score: <-MoCA Score->| A score of 26 or greater is considered normal.| | | Questions and Answers| | \n1. Alternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.| \n<*Answer_5540*>| 2. Cube-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is \nsimilar.| <*Answer_5541*>| 3. Draw a clock.| 3A. Clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).| <*Answer_5542*>| \n 3B. All clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; \nnumbers can be placed outside the circle contour. | <*Answer_5543*>| 3C. There must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute \nhand; hands must be centered within the clock face with their junction close to the clock center. | <*Answer_5544*>| 4. Name pictured animals| 4A. Lion| <*Answer_5545*>| 4B. \nRhinoceros or rhino| <*Answer_5546*>| 4C. Camel or dromedary| <*Answer_5547*>| 5. Attention| 5A. Forward Digit Span.| <*Answer_5548*>| 5B. Backward Digit Span. Correct \n
\n\n"], ["76", "STMS\n", "\n.| .| Short Test of Mental Status| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \ncomplete and correct.| <*Answer_5590*>| | 8. Information| 8A. Who is the current president of the United States?| <*Answer_5591*>| 8B. Who was the first president of the United States?| \n <*Answer_5592*>| 8C. Define an ISLAND.| <*Answer_5593*>| 8D. How many weeks are there in a year?| <*Answer_5594*>| | 9. Recall| 9A. Recall APPLE| <*Answer_5595*>| 9B. Recall \nMR. JOHNSON| <*Answer_5596*>| 9C. Recall CHARITY| <*Answer_5597*>| 9D. Recall TUNNEL| <*Answer_5598*>| | Copyright (c) 1987, Mayo Clinic Foundation. | | Information contained in this \nnote 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 \nactivities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | STMS Score: <-STMS Score->| | Questions and Answers| | 1. Orientation| 1A. What is your name?| <*Answer_5569*>| 1B. What \nis your address?| <*Answer_5570*>| 1C. What building are we in now?| <*Answer_5571*>| 1D. In what city are we now located?| <*Answer_5572*>| 1E. What state are we in now?| \n<*Answer_5573*>| 1F. What is today's date?| <*Answer_5574*>| 1G. What month is it?| <*Answer_5575*>| 1H. What year is it?| <*Answer_5576*>| | 2. Attention| 2A. Digit Span: \n2-9-6-8-3| <*Answer_5577*>| 2B. Digit Span: 5-7-1-9-4-6| <*Answer_5578*>| 2C. Digit Span: 2-1-5-9-3-6-2| <*Answer_5579*>| | 3. Immediate Recall| 3A. How many trials were needed to \nlearn all, some or none of the four words?| <*Answer_5580*>| 3B. How many words were learned?| <*Answer_5599*>| | 4. Calculation| 4A. What is 5 times 13?| <*Answer_5581*>| 4B. What \nis 65 minus 7?| <*Answer_5582*>| 4C. What is 58 divided by 2?| <*Answer_5583*>| 4D. What is 29 plus 11?| <*Answer_5584*>| | 5. Abstraction| 5A. How are ORANGE and BANANA alike?| \n <*Answer_5585*>| 5B. How are DOG and HORSE alike?| <*Answer_5586*>| 5C. How are TABLE and BOOKCASE alike?| <*Answer_5587*>| | 6. Construction| 6A. Clock face is circular, and numbers \nare correctly placed.| <*Answer_5588*>| 6B. The time is correctly drawn.| <*Answer_5589*>| | 7.Copy the line drawing of a three dimensional cube (Necker's cube). The subject's drawing is \n
\n\n"], ["77", "GDS\n", "\n.| .| Geriatric Depression Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nhappen to you?| <*Answer_5121*>| 7. Do you feel happy most of the time?| <*Answer_5122*>| 8. Do you often feel helpless?| <*Answer_5123*>| 9. Do you prefer to stay at home, rather than \ngoing out and doing new things?| <*Answer_5124*>| 10. Do you feel you have more problems with memory than most?| <*Answer_5125*>| 11. Do you think it is wonderful to be alive now?| \n<*Answer_5126*>| 12. Do you feel pretty worthless the way you are now?| <*Answer_5127*>| 13. Do you feel full of energy?| <*Answer_5128*>| 14. Do you feel that your situation is hopeless?| \n <*Answer_5129*>| 15. Do you think that most people are better off than you are?| <*Answer_5130*>| | | Information contained in this note is based on a self-report assessment and is not \nsufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| |\n GDS Mood Scale Score: <-Mood Scale->| | Although differing \nsensitivities and specificities have been obtained across \n| studies, for clinical purposes a score greater than 5 is suggestive of depression \n| and should warrant a follow-up interview. \n|| Scores greater than 10 almost always indicate depression. | | Questions\n and Answers| | 1. Are you basically satisfied with your life?| <*Answer_5116*>| 2. Have you dropped many of your activities and interests?| <*Answer_5117*>| 3. Do you feel that your life is \nempty?| <*Answer_5118*>| 4. Do you often get bored?| <*Answer_5119*>| 5. Are you in good spirits most of the time?| <*Answer_5120*>| 6. Are you afraid that something bad is going to \n
\n\n"], ["78", "VR-12\n", "\n.| .| The Veterans RAND 12-Item Health Survey| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nduring the past 4 weeks: | 6A. Have you felt calm and peaceful?| <*Answer_5608*>| 6B. Did you have a lot of energy?| <*Answer_5609*>| 6C. Have you felt downhearted and blue?| \n<*Answer_5610*>| 7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, \netc.)?| <*Answer_5611*>| 8. Compared to one year ago, how would you rate your physical health in general now?| <*Answer_5612*>| 9. Compared to one year ago, how would you rate your \nemotional problems (such as feeling anxious, depressed or irritable) now?| <*Answer_5613*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to \nuse alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>|| Physical Component Summary Score: <-PCS->| Higher scores indicate better health. Range is 1 to 72, Mean = 40, SD = 12.|| Mental \nComponent Summary Score: <-MCS-> | Higher scores indicate better health. Range is -2 to 76, Mean = 50, SD = 11.|| Questions and Answers| | 1. In general, would you say your health is:| \n<*Answer_5600*>| 2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? | 2A. Moderate activities, such as moving \na table, pushing a vacuum cleaner, bowling, or playing golf?| <*Answer_5601*>| 2B. Climbing several flights of stairs?| <*Answer_5602*>| 3. During the past 4 weeks, have you had any of \nthe following problems with your work or other regular daily activities as a result of your physical health?| 3A. Accomplished less than you would like.| <*Answer_5603*>| 3B. Were limited \nin the kind of work or other activities.| <*Answer_5604*>| 4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of \nany emotional problems (such as feeling depressed or anxious)?| 4A. Accomplished less than you would like.| <*Answer_5605*>| 4B. Didn't do work or other activities as carefully as usual.| \n <*Answer_5606*>| 5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and house work)?| <*Answer_5607*>| 6. How much of the time \n
\n\n"], ["79", "MOCA ALT 1\n", "\n.| .| Montreal Cognitive Assessment, Alternate 1| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \n2-5-8.| <*Answer_5623*>| 5C. Vigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).| <*Answer_5624*>| 5D. Serial 7s \nstarting at 90. Continue for five responses.| <*Answer_5625*>| 6. Language| 6A. Sentence repetition. A bird can fly into closed windows when it's dark and windy.| <*Answer_5626*>| 6B. \nSentence repetition. The caring grandmother sent groceries over a week ago.| <*Answer_5627*>| 7. Words beginning with the letter S.| <*Answer_5628*>| 8. Abstaction| 8A. Similarity between \nDIAMOND - RUBY.| <*Answer_5630*>| 8B. Similarity between CANNON - RIFLE.| <*Answer_5643*>| 9. Delayed recall| 9A. Recall TRUCK| <*Answer_5631*>| 9B. Recall BANANA.| \n<*Answer_5632*>| 9C. Recall VIOLIN.| <*Answer_5633*>| 9D. Recall DESK.| <*Answer_5634*>| 9E. Recall GREEN.| <*Answer_5635*>| 10. Orientation| 10A. Today's date,| \n<*Answer_5636*>| 10B. Current month| <*Answer_5637*>| 10C. Current year| <*Answer_5638*>| 10D. Day of the week| <*Answer_5639*>| 10E. What place is this?| <*Answer_5640*>| \n 10F. What city are we in?| <*Answer_5641*>| 11. Years of formal education:| <*Answer_5642*>| | Copyright (c) Z. Nasreddine MD| | Information contained in this note is based on a \nself-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 \nprocedures.| $~\nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | MoCA Score: <-MoCA Score->| | A score of 26 or greater is considered normal.| | Questions and Answers| | 1. \nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.| \n<*Answer_5614*>| 2. Rectangle-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is \ncorrect.| <*Answer_5615*>| 3. Draw a clock | 3A. Clock face must be a circle with only minor distortion acceptable (e.g.,| slight imperfection on closing the circle).| <*Answer_5616*>| \n 3B. All clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; \nnumbers can be placed outside the circle contour. | <*Answer_5617*>| 3C. There must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute \nhand; hands must be centered within the clock face with their junction close to the clock center. | <*Answer_5618*>| 4. Naming pictured animals| 4A. Giraffe| <*Answer_5619*>| 4B. Bear| \n <*Answer_5620*>| 4C. Hippopotamus| <*Answer_5621*>| 5. Attention| 5A. Forward Digit Span.| <*Answer_5622*>| 5B. Backward Digit Span. Correct response for the backwards trial is \n
\n\n"], ["8", "COMBAT EXPOSURE\n", "\n.|.|Combat Exposure Scale||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> \n(<.Patient_Age.>)|Gender: <.Patient_Gender.>||CES Scale: <-CES Scale->|| 0-8 Light exposure to combat| 9-16 Light to Moderate| 17-24 Moderate| 25-32 Moderate to Heavy| 33-41 \nHeavy exposure to combat||Questions and Answers||1. Did you ever go on combat patrols or have other dangerous duty?| <*Answer_4350*>|2. Were you ever under enemy fire?| <*Answer_4351*>|3. Were \nyou ever surrounded by the enemy?| <*Answer_4352*>|4. What percentage of the soldiers in your unit were killed (KIA), wounded or missing in action (MIA)?| <*Answer_4353*>|5. How often did you \nfire rounds at the enemy?| <*Answer_4354*>|6. How often did you see someone hit by incoming or outgoing rounds?| <*Answer_4355*>|7. How often were you in danger of being injured or killed \n(i.e., being pinned down, overrun, ambushed, near miss, etc.)?| <*Answer_4403*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["80", "MOCA ALT 2\n", "\n.| .| Montreal Cognitive Assessment, Alternate 2| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \n <*Answer_5653*>| 5C. Vigilance. Correct when there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A).| <*Answer_5654*>| 5D. Serial 7s starting at \n80. Continue for five responses.| <*Answer_5655*>| 6. Language| 6A. Sentence repetition. She heard his lawyer was the one to sue after the accident.| <*Answer_5656*>| 6B. Sentence \nrepetition. The little girls who were given too much candy got stomach aches.| <*Answer_5657*>| 7. Words beginning with the letter B.| <*Answer_5658*>| 8. Abstraction| 8A. Similarity \nbetween EYE - EAR.| <*Answer_5659*>| 8B. Similarity between TRUMPET - PIANO.| <*Answer_5660*>| 9. Delayed recall| 9A. Recall TRAIN| <*Answer_5661*>| 9B. Recall EGG.| \n<*Answer_5662*>| 9C. Recall HAT.| <*Answer_5663*>| 9D. Recall CHAIR.| <*Answer_5664*>| 9E. Recall BLUE.| <*Answer_5665*>| 10. Orientation| 10A. Today's date,| \n<*Answer_5666*>| 10B. Current month| <*Answer_5667*>| 10C. Current year| <*Answer_5668*>| 10D. Day of the week| <*Answer_5669*>| 10E. What place is this?| <*Answer_5670*>| \n 10F. What city are we in?| <*Answer_5671*>| 11. Years of formal education:| <*Answer_5672*>| | Copyright (c) Z. Nasreddine MD| | Information contained in this note is based on a \nself-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 \nprocedures.| $~\nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | MoCA Score: <-MoCA Score->| A score of 26 or greater is considered normal.| | | Questions and Answers| | 1. \nAlternating Trail Making. Correct Pattern: 1-A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected is scored incorrect.| \n<*Answer_5644*>| 2. Cylinder-Visuoconstructional Skills. Correct: All must be present: three-dimensional, all lines are drawn, no line is added, lines are relatively parallel and their length is \nsimilar.| <*Answer_5645*>| 3. Draw a clock| 3A. Clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle).| <*Answer_5646*>| \n3B. All clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; \nnumbers can be placed outside the circle contour. | <*Answer_5647*>| 3C. There must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute \nhand; hands must be centered within the clock face with their junction close to the clock center. | <*Answer_5648*>| 4. Name pictured animals| 4A. Donkey| <*Answer_5649*>| 4B. Pig| \n<*Answer_5650*>| 4C. Kangaroo| <*Answer_5651*>| 5. Attention| 5A. Forward Digit Span.| <*Answer_5652*>| 5B. Backward Digit Span. Correct response for the backwards trial is 1-7-4.| \n
\n\n"], ["81", "BARTHEL INDEX\n", "\n.|.|Barthel Index of Activities of Daily Living||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Barthel Index: <-Index->|| Range 0 - 100. Higher index values indicate independent living, low values indicate dependence on \nothers.||Questions and Answers||1. Bowels (preceding week):| <*Answer_5673*>|2. Bladder (preceding week):| <*Answer_5674*>|3. Grooming (preceding 24 - 48 hours):| <*Answer_5675*>|4. Toilet \nuse:| <*Answer_5676*>|5. Feeding:| <*Answer_5677*>|6. Transfer:| <*Answer_5678*>|7. Mobility:| <*Answer_5679*>|8. Dressing:| <*Answer_5680*>|9. Stairs:| <*Answer_5681*>|10. \nBathing:| <*Answer_5682*>||Copyright (c) 1965 Maryland State Medical Journal||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["82", "WHODAS 2\n", "\n.| .| World Health Organization Disability Assessment Schedule 2.0| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \nequivalent]?| <*Answer_5693*>| | Self-care| | D3.1 Washing your whole body?| <*Answer_5694*>| D3.2 Getting dressed?| <*Answer_5695*>| D3.3 Eating?| <*Answer_5696*>| D3.4 Staying \nby yourself for a few days?| <*Answer_5697*>| | Getting along| | D4.1 Dealing with people you do not know?| <*Answer_5698*>| D4.2 Maintaining a friendship?| <*Answer_5699*>| D4.3 \nGetting along with people who are close to you?| <*Answer_5700*>| D4.4 Making new friends?| <*Answer_5701*>| D4.5 Sexual activities?| <*Answer_5702*>| | Life activities| | D5.1 Taking \ncare of your household responsibilities?| <*Answer_5703*>| D5.2 Doing most important household tasks well?| <*Answer_5704*>| D5.3 Getting all the household work done that you needed to do?| \n <*Answer_5705*>| D5.4 Getting your household work done as quickly as needed?| <*Answer_5706*>| Do you work (paid, non-paid, self-employed) or go to school?| <*Answer_5707*>| D5.5 \nYour day-to-day work/school?| <*Answer_5708*>| D5.6 Doing your most important work/school tasks well?| <*Answer_5709*>| D5.7 Getting all the work done that you need to do?| \n<*Answer_5710*>| D5.8 Getting your work done as quickly as needed?| <*Answer_5711*>| | Participation in society| | D6.1 How much of a problem did you have in joining in community activities \n(for example, festivities, religious or other activities) in the same way as anyone else can?| <*Answer_5712*>| D6.2 How much of a problem did you have because of barriers or hindrances in the \nworld around you?| <*Answer_5713*>| D6.3 How much of a problem did you have living with dignity because of the attitudes and actions of others?| <*Answer_5714*>| D6.4 How much time did you \nspend on your health condition, or its consequences?| <*Answer_5715*>| D6.5 How much have you been emotionally affected by your health condition?| <*Answer_5716*>| D6.6 How much has your \n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | <*Answer_999999999999*>| | | Questions and Answers| | Understanding and communication| | D1.1 \nhealth been a drain on the financial resources of you or your family?| <*Answer_5717*>| D6.7 How much of a problem did your family have because of your health problems?| <*Answer_5718*>| \nD6.8 How much of a problem did you have in doing things by yourself for relaxation or pleasure?| <*Answer_5719*>| | H1. Overall, in the past 30 days, how many days were these difficulties \npresent?| <*Answer_5720*>| H2. In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?| <*Answer_5721*>| \nH3. In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?| \n<*Answer_5722*>| | | 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 \naccuracy and used in conjunction with other diagnostic activities and procedures.| $~\nConcentrating on doing something for ten minutes?| <*Answer_5683*>| \nD1.2 Remembering to do important things?| <*Answer_5684*>| D1.3 \nAnalyzing and finding solutions to problems in day-to-day \nlife?| <*Answer_5685*>| D1.4 Learning a new task, for example, learning how to get to a new place?| <*Answer_5686*>| D1.5 Generally understanding what people say?| <*Answer_5687*>| \nD1.6 Starting and maintaining a conversation?| <*Answer_5688*>| | \nGetting around| | D2.1 Standing for long periods such as 30 minutes?| <*Answer_5689*>| D2.2 Standing up from sitting \ndown?| <*Answer_5690*>| D2.3 Moving around inside your home?| <*Answer_5691*>| D2.4 Getting out of your home?| <*Answer_5692*>| D2.5 Walking a long distance such as a kilometer [or \n
\n\n"], ["83", "NEO-PI-3\n", "\n.|.|NEO Personality Inventory-3||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: \n<*Answer_5787*>|66. <*Answer_5788*> 67. <*Answer_5789*> 68. <*Answer_5790*> 69. <*Answer_5791*> 70. <*Answer_5792*>|71. <*Answer_5793*> 72. <*Answer_5794*> 73. <*Answer_5795*> 74. <*Answer_5796*> 75. \n<*Answer_5797*>|76. <*Answer_5798*> 77. <*Answer_5799*> 78. <*Answer_5800*> 79. <*Answer_5801*> 80. <*Answer_5802*>|81. <*Answer_5803*> 82. <*Answer_5804*> 83. <*Answer_5805*> 84. <*Answer_5806*> 85. \n<*Answer_5807*>|86. <*Answer_5808*> 87. <*Answer_5809*> 88. <*Answer_5810*> 89. <*Answer_5811*> 90. <*Answer_5812*>|91. <*Answer_5813*> 92. <*Answer_5814*> 93. <*Answer_5815*> 94. <*Answer_5816*> 95. \n<*Answer_5817*>|96. <*Answer_5818*> 97. <*Answer_5819*> 98. <*Answer_5820*> 99. <*Answer_5821*> 100. <*Answer_5822*>|101. <*Answer_5823*> 102. <*Answer_5824*> 103. <*Answer_5825*> 104. \n<*Answer_5826*> 105. <*Answer_5827*>|106. <*Answer_5828*> 107. <*Answer_5829*> 108. <*Answer_5830*> 109. <*Answer_5831*> 110. <*Answer_5832*>|111. <*Answer_5833*> 112. <*Answer_5834*> 113. \n<*Answer_5835*> 114. <*Answer_5836*> 115. <*Answer_5837*>|116. <*Answer_5838*> 117. <*Answer_5839*> 118. <*Answer_5840*> 119. <*Answer_5841*> 120. <*Answer_5842*>|121. <*Answer_5843*> 122. \n<*Answer_5844*> 123. <*Answer_5845*> 124. <*Answer_5846*> 125. <*Answer_5847*>|126. <*Answer_5848*> 127. <*Answer_5849*> 128. <*Answer_5850*> 129. <*Answer_5851*> 130. <*Answer_5852*>|131. \n<*Answer_5853*> 132. <*Answer_5854*> 133. <*Answer_5855*> 134. <*Answer_5856*> 135. <*Answer_5857*>|136. <*Answer_5858*> 137. <*Answer_5859*> 138. <*Answer_5860*> 139. <*Answer_5861*> 140. \n<*Answer_5862*>|141. <*Answer_5863*> 142. <*Answer_5864*> 143. <*Answer_5865*> 144. <*Answer_5866*> 145. <*Answer_5867*>|146. <*Answer_5868*> 147. <*Answer_5869*> 148. <*Answer_5870*> 149. \n<*Answer_5871*> 150. <*Answer_5872*>|151. <*Answer_5873*> 152. <*Answer_5874*> 153. <*Answer_5875*> 154. <*Answer_5876*> 155. <*Answer_5877*>|156. <*Answer_5878*> 157. <*Answer_5879*> 158. \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| NEO Personality Inventory-3||<*Answer_999999999999*>| \n<*Answer_5880*> 159. <*Answer_5881*> 160. <*Answer_5882*>|161. <*Answer_5883*> 162. <*Answer_5884*> 163. <*Answer_5885*> 164. <*Answer_5886*> 165. <*Answer_5887*>|166. <*Answer_5888*> 167. \n<*Answer_5889*> 168. <*Answer_5890*> 169. <*Answer_5891*> 170. <*Answer_5892*>|171. <*Answer_5893*> 172. <*Answer_5894*> 173. <*Answer_5895*> 174. <*Answer_5896*> 175. <*Answer_5897*>|176. \n<*Answer_5898*> 177. <*Answer_5899*> 178. <*Answer_5900*> 179. <*Answer_5901*> 180. <*Answer_5902*>|181. <*Answer_5903*> 182. <*Answer_5904*> 183. <*Answer_5905*> 184. <*Answer_5906*> 185. \n<*Answer_5907*>|186. <*Answer_5908*> 187. <*Answer_5909*> 188. <*Answer_5910*> 189. <*Answer_5911*> 190. <*Answer_5912*>|191. <*Answer_5913*> 192. <*Answer_5914*> 193. <*Answer_5915*> 194. \n<*Answer_5916*> 195. <*Answer_5917*>|196. <*Answer_5918*> 197. <*Answer_5919*> 198. <*Answer_5920*> 199. <*Answer_5921*> 200. <*Answer_5922*>|201. <*Answer_5923*> 202. <*Answer_5924*> 203. \n<*Answer_5925*> 204. <*Answer_5926*> 205. <*Answer_5927*>|206. <*Answer_5928*> 207. <*Answer_5929*> 208. <*Answer_5930*> 209. <*Answer_5931*> 210. <*Answer_5932*>|211. <*Answer_5933*> 212. \n<*Answer_5934*> 213. <*Answer_5935*> 214. <*Answer_5936*> 215. <*Answer_5937*>|216. <*Answer_5938*> 217. <*Answer_5939*> 218. <*Answer_5940*> 219. <*Answer_5941*> 220. <*Answer_5942*>|221. \n<*Answer_5943*> 222. <*Answer_5944*> 223. <*Answer_5945*> 224. <*Answer_5946*> 225. <*Answer_5947*>|226. <*Answer_5948*> 227. <*Answer_5949*> 228. <*Answer_5950*> 229. <*Answer_5951*> 230. \n<*Answer_5952*>|231. <*Answer_5953*> 232. <*Answer_5954*> 233. <*Answer_5955*> 234. <*Answer_5956*> 235. <*Answer_5957*>|236. <*Answer_5958*> 237. <*Answer_5959*> 238. <*Answer_5960*> 239. \n<*Answer_5961*> 240. <*Answer_5962*>||A. <*Answer_5963*> B. <*Answer_5964*> C. <*Answer_5965*>|||Copyright (c) 1978, 1985, 1989, 1991, 1992, 2010 by PAR. All rights reserved.||Information contained \n| Questions and Answers:||1. <*Answer_5723*> 2. <*Answer_5724*> 3. <*Answer_5725*> 4. <*Answer_5726*> 5. \nin 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 \ndiagnostic activities and procedures.| $~\n<*Answer_5727*>|6. <*Answer_5728*> 7. <*Answer_5729*> 8. <*Answer_5730*> 9. <*Answer_5731*> 10. <*Answer_5732*>|11. <*Answer_5733*> 12. <*Answer_5734*> 13. <*Answer_5735*> 14. <*Answer_5736*> 15. \n<*Answer_5737*>|16. <*Answer_5738*> 17. <*Answer_5739*> 18. <*Answer_5740*> 19. <*Answer_5741*> 20. <*Answer_5742*>|21. <*Answer_5743*> 22. <*Answer_5744*> 23. <*Answer_5745*> 24. <*Answer_5746*> 25. \n<*Answer_5747*>|26. <*Answer_5748*> 27. <*Answer_5749*> 28. <*Answer_5750*> 29. <*Answer_5751*> 30. <*Answer_5752*>|31. <*Answer_5753*> 32. <*Answer_5754*> 33. <*Answer_5755*> 34. <*Answer_5756*> 35. \n<*Answer_5757*>|36. <*Answer_5758*> 37. <*Answer_5759*> 38. <*Answer_5760*> 39. <*Answer_5761*> 40. <*Answer_5762*>|41. <*Answer_5763*> 42. <*Answer_5764*> 43. <*Answer_5765*> 44. <*Answer_5766*> 45. \n<*Answer_5767*>|46. <*Answer_5768*> 47. <*Answer_5769*> 48. <*Answer_5770*> 49. <*Answer_5771*> 50. <*Answer_5772*>|51. <*Answer_5773*> 52. <*Answer_5774*> 53. <*Answer_5775*> 54. <*Answer_5776*> 55. \n<*Answer_5777*>|56. <*Answer_5778*> 57. <*Answer_5779*> 58. <*Answer_5780*> 59. <*Answer_5781*> 60. <*Answer_5782*>|61. <*Answer_5783*> 62. <*Answer_5784*> 63. <*Answer_5785*> 64. <*Answer_5786*> 65. \n
\n\n"], ["84", "VRA\n", "\n.| .| Veteran Recovery Assessment| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nor more additional friends, please check "Yes, more support".) | <*Answer_5977*>| | 8. Housing| | 8A. Choose the following sentence that best describes your current goal about your \nhousing:| <*Answer_5978*>| 8B. Choose the following sentence that best describes your current situation:| <*Answer_5979*>| | 9. Employment| | 9A. Choose the following sentence that \nbest describes your current goal regarding employment:| <*Answer_5980*>| 9B. Choose the following sentence that best describes your current situation:| <*Answer_5981*>| | 10. \nInvolvement in the Community| | 10A. Choose the following sentence that best describes your current interest in being involved in the community:| <*Answer_5982*>| 10B. Choose the following \nsentence that best describes your current situation:| <*Answer_5983*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for \ndiagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Questions and Answers| | 1. I have my own plan for how to stay or become well.| <*Answer_5966*>| 2. I have goals \nin life that I want to reach.| <*Answer_5967*>| 3. I'm hopeful about my future.| <*Answer_5968*>| 4. Coping with my mental illness is no longer the main focus of my life.| \n<*Answer_5969*>| 5. I have people in the community I can count on.| <*Answer_5970*>| 6. My mental health providers encourage me to take the lead in setting my personal treatment and life \ngoals.| <*Answer_5971*>| | 7. Support for Recovery | | 7A. Do you currently get support for your recovery from your spouse or significant other?| <*Answer_5972*>| 7B. Do you \ncurrently get support for your recovery from other family members?| <*Answer_5973*>| 7C. Do you currently get support for your recovery from friends?| <*Answer_5974*>| 7D. Would you \nlike a change in the kind or amount of support for your recovery that you are getting from your spouse or significant other? (If you do not have a spouse or significant other but want one, please \ncheck "Yes, more support".) | <*Answer_5975*>| 7E. Would you like a change in the kind or amount of support for your recovery that you are getting from other family members?| \n<*Answer_5976*>| 7F. Would you like a change in the kind or amount of support for your recovery that you are getting from friends? (If you do not have as many friends as you would like but want one \n
\n\n"], ["85", "SBR II DRAFT\n", "\n.| .| Suicide Behavior Report| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \nDOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Self-Directed Violence (SDV) Classification System:| <.DLL_String.>| | Questions and Answers| | 1. Is \nthere any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful?| <*Answer_5984*>| 2. Is there any indication that the person had \nself-directed violence related thoughts?| <*Answer_5985*>| 2A. Were/Are the thoughts suicidal?| <*Answer_5986*>| 3. Did the behavior involve any injury?| <*Answer_5987*>| 3A. \nWas the injury fatal?| <*Answer_5988*>| 3B. Was the behavior preparatory only?| <*Answer_5989*>| 3C. Was the behavior interrupted by self or other(s)?| <*Answer_5990*>| 4. Is \nthere evidence of Suicidal Intent?| <*Answer_5991*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["86", "SSF\n", "\n.| .| Status of Suicide Form| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \ndisliking yourself; having no self-esteem; having no self-respect): (1-Low self-hate, 5-High self-hate) <*Answer_6009*>| 5A) What I hate most about myself is:| <*Answer_6010*>| \n5B) Rank of importance: <*Answer_6011*>| | 6) RATE OVERALL RISK OF SUICIDE: (1-Extremely low risk, 5-Extremely high risk) <*Answer_6012*>| | 7) How much is being suicidal related to \nthoughts and feelings about yourself? (1-Not at all, 5-Completely) <*Answer_6013*>| | 8) How much is being suicidal related to thoughts and feelings about others? (1-Not at all, 5-Completely) \n<*Answer_6014*>| | Copyright (c) David A. Jobes, Ph.D.| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Status of Suicide| | Pain (1-Low pain, 5-High pain): <-Pain->| Stress (1-Low stress, 5-High stress): \n<-Stress->| Agitation (1-Low agitation, 5-High agitation): <-Agitation->| Hopelessness (1-Low hopelessness, 5-High hopelessness): <-Hopelessness->| Self-Hate (1-Low self-hate, \n5-High self-hate): <-Self-Hate->| | Questions and Answers| | 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain):(1-Low pain, 5-High pain) \n<*Answer_5997*>| 1A) What I find most painful is:| <*Answer_5998*>| 1B) Rank of importance: <*Answer_5999*>| | 2) RATE STRESS (your general feeling of being pressured or \noverwhelmed): (1-Low stress, 5-High stress) <*Answer_6000*>| 2A) What I find most stressful is:| <*Answer_6001*>| 2B) Rank of importance: <*Answer_6002*>| | 3) RATE \nAGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): (1-Low agitation, 5-High agitation) <*Answer_6003*>| 3A) I most need to take action when:| \n <*Answer_6004*>| 3B) Rank of importance: <*Answer_6005*>| | 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): (1-Low hopelessness, \n5-High hopelessness) <*Answer_6006*>| 4A) I am most hopeless about:| <*Answer_6007*>| 4B) Rank of importance: <*Answer_6008*>| | 5) RATE SELF-HATE (your general feeling of \n
\n\n"], ["87", "MMPI-2-RF\n", "\n.| .| | Minnesota Multiphasic Personality Inventory-2-Restructured Form| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>||<*Answer_999999999999*>$~\n
\n\n"], ["88", "BAM-C\n", "\n.| .| Brief Addiction Monitor - Consumption Items| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \namphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, "speed", "crystal meth", "ice", etc.)?| <*Answer_6470*>| | 4E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, \ncodeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?| <*Answer_6471*>| | 4F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_6472*>| \n| 4G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?| <*Answer_6473*>| | | Information contained in \nthis 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 \ndiagnostic activities and procedures.| $~\n<.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 \nOther 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.| \n | Questions and Answers| | A. Date of administration:| \n<*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, \nhow 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 \nor 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*>| \n | 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 \n(benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?| <*Answer_6468*>| | 4C. Cocaine and/or Crack?| <*Answer_6469*>| | 4D. Other Stimulants (e.g., \n
\n\n"], ["89", "QOLI\n", "\n.| .| Quality of Life Inventory| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| \n DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>|||INTRODUCTION|\n The Quality of Life Inventory (QOLI) provides a score that indicates a|\n person's overall satisfaction with life. People's life satisfaction is based|\n on how well their needs, goals, and wishes are being met in important areas|\n of life.|<*Answer_999999999999*>||\n Copyright (c) 1988, 1994 Michael B. Frisch Ph.D. All rights reserved.| $~\n
\n\n"], ["9", "File: 601.71, IEN: 100108\n", "\n WHYMPI Date Given: <.Date Given.> Clinician: <.Staff: Ordered By.> Location: <.Location.> Veteran: <.Patient Name: Last, First.> SSN: <.Patient: SSN.> DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>) Gender: <.Patient: Gender.> SDasdasD This is a sample report to help you get started. AsdsD A Use the right button of the mouse to display editing options (these also appear in the Navigation panel). Instructions appear in the lower panel and will change depending upon the location of the mouse. You will need to delete these instructions later. A script is narrative text for an answer to a question, for example, "Mr. March claimed to be married." $~\n
\n\n"], ["90", "BAM-R\n", "\n| .| .| Brief Addiction Monitor - Revised| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n to 180. For subscale scores, items with ordinal response options (0-4) were|\n converted to contribute proportionately consistent with items on days of use|\n (0-30). Clinicians are encouraged to consider scores on individual Risk items|\n in offering interventions as indicated during initial treatment planning and|\n following re-assessment.||\n Protective Factors: <-Protective Factors->|\n Items 9, 10, 12, 13, 14, 16. A high score indicates greater protective|\n factors, range is 0 to 180. For subscale scores, items with ordinal response|\n options (0-4) were converted to contribute proportionately consistent with|\n items on days of use (0-30). Clinicians are encouraged to consider scores on|\n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | |Clinical Subscales||\n individual Protective items in offering interventions as indicated during|\n initial treatment planning and following re-assessment.|||\n Questions and Answers ||\n A. Date of administration:| <*Answer_6474*>| |\n B. Method of administration:| <*Answer_6475*>| |\n 1. In the past 30 days, how would you say your physical health has been?| <*Answer_6476*>| |\n 2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?| <*Answer_6499*>||\n 3. In the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?| <*Answer_6500*>| |\n 4. In the past 30 days, how many days did you drink ANY alcohol?| <*Answer_6501*>| |\n 5. 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)?|\n Use: <-Use->|\n [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_6502*>| |\n 6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?| <*Answer_6503*>| |\n 7A. Marijuana (cannabis, pot, weed)?| <*Answer_6504*>| |\n 7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?| <*Answer_6505*>| |\n 7C. Cocaine and/or Crack?| <*Answer_6506*>| |\n 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?| <*Answer_6507*>| | \n 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?| <*Answer_6508*>| |\n 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_6509*>| |\n 7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?| <*Answer_6510*>| |\n 8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?| <*Answer_6489*>| |\n Items 4, 5, 6. A high score indicates more use, range is 0 to 90. If a|\n 9. How confident are you that you will NOT use alcohol and drugs in the next 30 days?| <*Answer_6490*>| |\n 10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?| <*Answer_6511*>| |\n 11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky "people, places or things")?| <*Answer_6512*>| |\n 12. Does your religion or spirituality help support your recovery?| <*Answer_6493*>| |\n 13. In the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?| <*Answer_6513*>| |\n 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_6495*>| |\n 15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?| <*Answer_6496*>| |\n 16. In the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?| <*Answer_6514*>| |\n 17. How satisfied are you with your progress toward achieving your recovery goals?| <*Answer_6498*>| | |\n 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 \n patient scores a 1 or greater, it calls for further assessment and clinical|\nfor accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n attention, e.g., consider addition/change of pharmacotherapy or psychosocial|\n intervention.||\n Risk Factors: <-Risk Factors->|\n Items 1, 2, 3, 8, 11, 15. A high score indicates increased risk, range is 0|\n
\n\n"], ["91", "BAM-IOP\n", "\n.| .| Brief Addiction Monitor: IOP version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nday?| <*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 \ndrinks (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.] | \n<*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, \nhow 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, \nAmbien, barbs, Phenobarbital, downers, etc.)?| <*Answer_6448*>| 7C. Cocaine and/or Crack?| <*Answer_6449*>| 7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, \nRitalin, Adderall, speed, crystal meth, ice, etc.)?| <*Answer_6450*>| 7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, \nFentanyl, etc.)?| <*Answer_6451*>| 7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?| <*Answer_6452*>| 7G. Other drugs (steroids, non-prescription \nsleep 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 \ndrink 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 \ndays, 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 \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Clinical Subscales:| | Use: <-Use->| Items 4, 5, 6. A high score \nany 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 \nhelp 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*>| \n| 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*>| | \n15. 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 \ndays 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 \nachieving 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. \nAssessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nindicates 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 \nintervention. | | 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 \nindividual Risk items in offering interventions as indicated during initial treatment planning and following re-assessment.| | Protective Factors: <-Protective Factors->| Items 9, \n10, 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 \nindicated during initial treatment planning and following re-assessment.| | | Questions and Answers| | A. Date of administration:| <*Answer_6439*>| B. Method of \nadministration:| <*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 \nyou 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 \n
\n\n"], ["93", "STOP\n", "\n.| .| Snoring, Tired, Observed, Blood Pressure| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \n<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | STOP Score: <-STOP->| | \nHigh risk of obstructive sleep apnea: a STOP score of 2 or more| Low risk of obstructive sleep apnea: a STOP score 1 or less| | | Questions and Answers| | 1. Do you snore \nloudly (louder than talking or loud enough to be heard through closed doors)?| <*Answer_6517*>| 2. Do you often feel tired, fatigued or sleepy during daytime?| <*Answer_6516*>| \n 3. Has anyone observed you stop breathing during your sleep?| <*Answer_6518*>| 4. Do you have or are you being treated for high blood pressure?| <*Answer_6519*>| | \n| 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 \nused in conjunction with other diagnostic activities and procedures.| $~\n
\n\n"], ["94", "ZZMDQ-OLD\n", "\n.| .| Mood Disorders Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nhave several of these ever happened during the same period of time?| <*Answer_6534*>| 3. How much of a problem did any of these cause you, like being unable to work; having family, money, or \nlegal troubles; or getting into arguments or fights?| <*Answer_6535*>| 4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive \nillness or bipolar disorder?| <*Answer_7292*>| 5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?| <*Answer_7293*>| | (c) 2000 by The \nUniversity of Texas Medical Branch.| | 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 \nbe verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Has there ever been a time when you were not your usual self and...| | 1A. \nyou felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?| <*Answer_6521*>| 1B. you were so irritable that you shouted \nat people or started fights or arguments?| <*Answer_6522*>| 1C. you felt much more self-confident than usual?| <*Answer_6523*>| 1D. you got much less sleep than usual and found you didn't \nreally miss it?| <*Answer_6524*>| 1E. you were much more talkative or spoke faster than usual?| <*Answer_6525*>| 1F. thoughts raced through your head or you couldn't slow your mind down?| \n<*Answer_6526*>| 1G. you were so easily distracted by things around you that you had trouble concentrating or staying on track?| <*Answer_6527*>| 1H. you had much more energy than usual?| \n<*Answer_6528*>| 1I. you were much more active or did many more things than usual?| <*Answer_6529*>| 1J. you were much more social or outgoing than usual? For example, you telephoned friends in \nthe middle of the night.| <*Answer_6530*>| 1K. you were much more interested in sex than usual?| <*Answer_6531*>| 1L. you did things that were unusual for you or that other people might have \nthought were excessive, foolish, or risky?| <*Answer_6532*>| 1M. spending money got you or your family into trouble?| <*Answer_6533*>| 2. If you answered YES to more than one of the above, \n
\n\n"], ["95", "PSOCQ\n", "\n.| .| Pain Stages of Change Questionnaire - PSOCQ| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \nI realize now that it's time for me to come up with a better plan to cope with my pain problem.| <*Answer_6546*>| 12. I am beginning to wonder if I need to get some help to cope with my pain \nproblem.| <*Answer_6547*>| 13. I have recently figured out that it's up to me to deal better with my pain.| <*Answer_6548*>| 14. I have recently come to the conclusion that it's time for \nme to change how I cope with my pain.| <*Answer_6549*>| 15. I'm starting to wonder whether it's up to me to manage my pain rather than relying on physicians.| <*Answer_6550*>| 16. I have \nbeen thinking that doctors can only help so much in managing my pain and that the rest is up to me.| <*Answer_6551*>| 17. I have been wondering if there is something I could do to manage my \npain better.| <*Answer_6552*>| | Action:| 18. I am developing new ways to cope with my pain.| <*Answer_6553*>| 19. I have started to come up with strategies to help myself control my \npain.| <*Answer_6554*>| 20. I'm getting help learning some strategies for coping better with my pain.| <*Answer_6555*>| 21. I am learning to help myself control my pain without doctors.| \n <*Answer_6556*>| 22. I am testing out some coping skills to manage my pain better.| <*Answer_6557*>| 23. I am learning ways to control my pain other than with medications or surgery.| \n<*Answer_6558*>| | Maintenance:| 24. I have learned some good ways to keep my pain problem from interfering with my life.| <*Answer_6560*>| 25. When my pain flares up, I find myself \nautomatically using coping strategies that have worked in the past, such as relaxation exercise or mental distraction.| <*Answer_6561*>| 26. I am using some strategies that help me better deal \nwith my pain problem on a day-to-day basis.| <*Answer_6562*>| 27. I use what I have learned to help keep my pain under control.| <*Answer_6563*>| 28. I am currently using some suggestions \n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | PSOCQ Scale Scores| | Precontemplation: <-Precontemplation->| \npeople have made about how to live with my pain problem.| <*Answer_6564*>| 29. I have incorporated strategies for dealing with my pain into my everyday life.| <*Answer_6565*>| 30. I have \nmade a lot of progress in coping with my pain.| <*Answer_6566*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic \npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~\nContemplation: <-Contemplation->| Action: <-Action->| Maintenance: <-Maintenance->| | Questions and Answers| | Precontemplation:| 1. I have tried everything that \npeople have recommended to manage my pain and nothing helps.| <*Answer_6536*>| 2. My pain is a medical problem and I should be dealing with physicians about it.| <*Answer_6537*>| 3. \nEverybody I speak with tells me that I have to learn to live with my pain, but I don't see why I should have to.| <*Answer_6538*>| 4. I still think despite what doctors tell me, there must be \nsome surgical procedure or medication that would get rid of my pain.| <*Answer_6539*>| 5. The best thing I can do is find a doctor who can figure out how to get rid of my pain once and for \nall.| <*Answer_6540*>| 6. Why can't someone just do something to take away my pain?| <*Answer_6541*>| 7. All of this talk about how to cope better is a waste of my time.| \n<*Answer_6542*>| | Contemplation:| 8. I have been thinking that the way I cope with my pain could improve.| <*Answer_6543*>| 9. I have recently realized that there is no medical cure for my \npain condition, so I want to learn some ways to cope with it.| <*Answer_6544*>| 10. Even if my pain doesn't go away, I am ready to start changing how I deal with it.| <*Answer_6545*>| 11. \n
\n\n"], ["96", "PSS\n", "\n.| .| Perceived Stress Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \n | 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 \nused in conjunction with other diagnostic activities and procedures.| $~\n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | PSS Score: <-PSS->| | A high score indicates a high level of \nstress: the range is 0 to 40.| | | Questions and Answers| | 1. In the last month, how often have you been upset because of something that happened unexpectedly?| \n<*Answer_6567*>| 2. In the last month, how often have you felt that you were unable to control the important things in your life?| <*Answer_6568*>| 3. In the last month, how often \nhave you felt nervous and stressed?| <*Answer_6569*>| 4. In the last month, how often have you felt confident about your ability to handle your personal problems?| \n<*Answer_6570*>| 5. In the last month, how often have you felt that things were going your way?| <*Answer_6571*>| 6. In the last month, how often have you found that you could not \ncope with all the things that you had to do?| <*Answer_6572*>| 7. In the last month, how often have you been able to control irritations in your life?| <*Answer_6573*>| 8. \nIn the last month, how often have you felt that you were on top of things?| <*Answer_6574*>| 9. In the last month, how often have you been angered because of things that were outside of \nyour control?| <*Answer_6575*>| 10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?| <*Answer_6576*>| | \n
\n\n"], ["97", "PSS\n", "\n.| .| PERCEIVED STRESS SCALE| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nThe PSS Scale is reprinted with permission of the American Sociological Association, from Cohen, S., Kamarck, T., and Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health \nand Social Behavior, 24, 386-396. Cohen, S. and Williamson, G. Perceived Stress in a Probability Sample of the United States. Spacapan, S. and Oskamp, S. (Eds.) The Social| Psychology of Health. \nNewbury Park, CA: Sage, 1988.| $~\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | Score: <-Scale->| | Questions and Answers| | 1. In the last month, how often have you been upset because of something \nthat happened unexpectedly?| <*Answer_6567*>| 2. In the last month, how often have you felt that you were unable to control the important things in your life?| <*Answer_6568*>| 3. In the last \nmonth, how often have you felt nervous and stressed?| <*Answer_6569*>| 4. In the last month, how often have you felt confident about your ability to handle your personal problems?| \n<*Answer_6570*>| 5. In the last month, how often have you felt that things were going your way?| <*Answer_6571*>| 6. In the last month, how often have you found that you could not cope with all \nthe things that you had to do?| <*Answer_6572*>| 7. In the last month, how often have you been able to control irritations in your life?| <*Answer_6573*>| 8. In the last month, how often have \nyou felt that you were on top of things?| <*Answer_6574*>| 9. In the last month, how often have you been angered because of things that were outside of your control?| <*Answer_6575*>| 10. In \nthe last month, how often have you felt difficulties were piling up so high that you could not overcome them?| <*Answer_6576*>| | | Information contained in this note is based on a self-report \nassessment 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.| | \n
\n\n"], ["98", "CAM\n", "\n.| .| Confusion Assessment Method| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \nand decrease in severity)?| <*Answer_7297*>| 5C. (If present or abnormal) Please describe this behavior.| <*Answer_7298*>| 6A. Did the patient demonstrate any memory problems during the \ninterview, such as inability to remember events in the hospital or difficulty remembering instructions?| <*Answer_6584*>| 6B. (If present or abnormal) Did this behavior fluctuate during the \ninterview (that is, tend | to come-and-go or increase and decrease in severity)?| <*Answer_7299*>| 6C. (If present or abnormal) Please describe this behavior.| <*Answer_7300*>| 7A. Did \nthe patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or misinterpretations (for example, thinking something was moving when it was not)?| <*Answer_6585*>| \n 7B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend | to come-and-go or increase and decrease in severity)?| <*Answer_7301*>| 7C. (If present or \nabnormal) Please describe this behavior.| <*Answer_7302*>| 8A. At any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness, \npicking at bedclothes, tapping fingers, or making frequent, sudden changes in position? | <*Answer_6586*>| 8AB. (If present or abnormal) Did this behavior fluctuate during the interview (that \nis, tend to come-and-go or increase and decrease in severity)?| <*Answer_7304*>| 8AC. (If present or abnormal) Please describe this behavior.| <*Answer_7305*>| 8BA. At any time during the \ninterview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly? | \n<*Answer_6587*>| 8BB. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?| <*Answer_7306*>| 8BC. (If \n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | Questions and Answers| | 1. Is there evidence of an acute change in mental status from the \npresent or abnormal) Please describe this behavior.| <*Answer_7307*>| 9A. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with \ninsomnia at night?| <*Answer_7303*>| 9B. If yes, please describe the disturbance:| <*Answer_7308*>| | Copyright (c) 2003 Hospital Elder Life Program, LLC| | Information contained in \nthis 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 \ndiagnostic activities and procedures.| $~\npatient's baseline?| <*Answer_6577*>| 2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty keeping track of what was being said)?| \n <*Answer_6578*>| 2B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come-and-go or increase and decrease in severity)?| <*Answer_6579*>| 2C. \n(If present or abnormal) Please describe this behavior.| <*Answer_6580*>| 3A. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or \nillogical flow of ideas, or unpredictable, switching from subject to subject?| <*Answer_6581*>| 3B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to \ncome-and-go or increase and decrease in severity)?| <*Answer_7295*>| 3C. (If present or abnormal) Please describe this behavior.| <*Answer_7296*>| 4. Overall, how would you rate this \npatient's level of consciousness?| <*Answer_6582*>| 5A. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, \nusing the wrong bed, or misjudging the time of day?| <*Answer_6583*>| 5B. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend | to come-and-go or increase \n
\n\n"], ["99", "D.BAS\n", "\n.| .| Dysfunctional Beliefs and Attitudes About Sleep (DBAS-16)| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \n5. After a poor night's sleep, I know that it will interfere with my daily activities on the next day.| <*Answer_6593*>|\n6. In order to be alert and function well during the day, I am better off taking a sleeping pill rather than having a poor night's sleep.| <*Answer_6594*>|\n7. When I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before.| <*Answer_6595*>|\n8. When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.| <*Answer_6596*>|\n9. Without an adequate night's sleep, I can hardly function the next day.| <*Answer_6597*>|\n10. I can't ever predict whether I will have a good or poor night's sleep.| <*Answer_6598*>|\n11. I have little ability to manage the negative consequences of disturbed sleep.| <*Answer_6599*>|\n12. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.| <*Answer_6600*>|\n13. I believe that insomnia is essentially the result of a chemical imbalance.| <*Answer_6601*>|\n14. I feel that insomnia is ruining my ability to enjoy life and prevents me from doing what I want.| <*Answer_6602*>|\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | |\n15. Medication is probably the only solution to sleeplessness.| <*Answer_6603*>|\n16. I avoid or cancel obligations (social, family, occupational) after a poor night's sleep.| <*Answer_6604*>|\n| | 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\n other diagnostic activities.| $~\nDBAS-16 Total Score = <-TOTAL SCORE->|\n| Higher scores reflect greater dysfunctional beliefs about sleep. Target beliefs expressed in items with scores greater than 5.| |\nQuestions and Answers| |\n1. I need 8 hours of sleep to feel refreshed and function well during the day.| <*Answer_6589*>|\n2. When I do not get the proper amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.| <*Answer_6590*>|\n3. I am concerned that chronic insomnia may have serious consequences for my physical health.| <*Answer_6591*>|\n4. I am worried that I may lose control over my abilities to sleep.| <*Answer_6592*>|\n
\n\n"]]}