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"instrument":142,"template":".| .| Client Evaluation of Motivational Interviewing| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: \r\n<.Patient_SS
N.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Technical Factor: <-Technical Factor->| Relationship \r\nFactor: <-Relationship Factor->| |
CEMI Total: <*Answer_7772*>| | | Scores range from 16-64 with higher scores being more motivational Interviewing (MI)consistent| | \r\nTechnical Factor:| Scores range from 8-32 with higher scores being more motiv
ational Interviewing (MI)consistent| | Relationship Factor: | Scores range from 8-32 with higher \r\nscores being more motivational Interviewing (MI)consistent| | | Questions and Answers| | 1. Focus on your weakness.|
<*Answer_6405*>| 2. Help you to talk about changing your \r\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.| <*Ans
wer_6408*>| 5. Make you \r\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 \r\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*>| \r\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.| \r\n<*Answer_6479*>| 13. Argue with you about needing to be 100% ready to change your behavior.|
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"instrument":207,"introDisplay":98138,"introId":2178,"introText":"1. In your Lifetime, which of the following substances have you ever used? | (Note: For prescription medications, please report nonmedical use only.) ","max":0,"min":0,"ques
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tionDisplay":139,"questionId":7322,"questionText":"ANXIETY - Ask, \"Do you feel nervous?\" Observation:","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":70},{"choice":[{"choiceId":2473,"choiceText":"Normal activi
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:3},{"choiceId":2752,"choiceText":"Agitation 3","ien":106598,"legacyValue":3,"sequence":4},{"choiceId":2477,"choiceText":"Moderately fidgety and restless","ien":106599,"legacyValue":4,"sequence":5},{"choiceId":2753,"choiceText":"Agitation 5
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,{"choiceId":2438,"choiceText":"Mild itching, pins and needles, burning or numbness","ien":106605,"legacyValue":2,"sequence":3},{"choiceId":2439,"choiceText":"Moderate itching, pins and needles, burning or numbness","ien":106606,"legacyValu
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CES - Ask, \"Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?\" Observation:","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":90},{
"choice":[{"choiceId":614,"choiceText":"Not present","ien":106611,"legacyValue":0,"sequence":1},{"choiceId":2450,"choiceText":"Very mild harshness or ability to frighten","ien":106612,"legacyValue":1,"sequence":2},{"choiceId":2451,"choiceTe
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\r\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 \r\nwithdrawal. | Scores of 8 to 15 indi
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cate moderate withdrawal (marked autonomic arousal).| Scores of 15 or more indicate severe withdrawal (impending delirium tremens). | | Questions and Answers| | 1. \r\nTime (use 24 hour clock, midnight is 00:00):| <*Answer_7313*>| 2. Pu
lse or heart rate (taken for one minute):| <*Answer_7314*>| 3. Blood pressure:| <*Answer_7315*>| 4. NAUSEA AND VOMITING \r\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 \r\nSWEATS - Observation:| <*Answer_7320*>| 7. ANXIETY - Ask, \"Do you feel nervous?\" Observation:| <*Answer_7322*>| 8. AGITATION - Observat
ion:| <*Answer_7324*>| 9. TACTILE DISTURBANCES - \r\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. AUDIT
ORY DISTURBANCES - \r\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?\" \r\nObservation: | <*An
swer_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 \r\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 \r\naround your head?\" Do not rate for dizziness or lightheadedness. Otherwise, rate severity:|
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n.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: \r\n<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | CSI Score: <-CSI->| | | Questions and Answers| | 1. Please indicate the degree of
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\r\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.| \r\n<*Answer_6486*>| 4. My relationshi
p 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 \r\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?| \r\n<*Answer_6494*>| 9. To what extent has your relationship met your original expectations?| <*Answer_6497*>| 10. In genera
l, how satisfied are you with your relationship?| <*Answer_6559*>| 11. \r\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 \r\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*>| \r\n|
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"1. In your Lifetime, which of the following substances have you ever used? | (Note: For prescription medications, please report nonmedical use only.) ","max":0,"min":0,"questionDisplay":98215,"questionId":6966,"questionText":"During the p
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ast 3 months, how often has your use of street opioids (heroin, opium, etc.) led to health, social, legal or financial problems?","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":460},{"choice":[{"choiceId":217,"c
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wer_7772*>| Action: <*Answer_7773*>| Maintenance: <*Answer_7774*>| | Questions and Answers| | Precontemplation:| 1. I have tried everything that \r\npeople have recommended to manage my pain and nothing hel
ps.| <*Answer_6536*>| 2. My pain is a medical problem and I should be dealing with physicians about it.| <*Answer_6537*>| 3. \r\nEverybody I speak with tells me that I have to learn to live with my pain, but I don't see why I sh
ould have to.| <*Answer_6538*>| 4. I still think despite what doctors tell me, there must be \r\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 \r\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 ti
me.| \r\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 \r\npain condition, so I wa
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nt 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. \r\nI realize now that it's time for me to come up with a bette
r 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 \r\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
\r\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 \r\nbeen thinking that doctors can on
ly 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 \r\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 \r\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.| \r\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.| \r\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 \r\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 \r\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 \r\npeople have made about how to live with my pain problem.|
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<*Answer_6564*>| 29. I have incorporated strategies for dealing with my pain into my everyday life.| <*Answer_6565*>| 30. I have \r\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 \r\npurposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.|
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Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| \r\n SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | PSS Score: <-PSS->| |
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A high score indicates a high level of \r\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?|
\r\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 \r\nhave you felt nervous and stress
ed?| <*Answer_6569*>| 4. In the last month, how often have you felt confident about your ability to handle your personal problems?| \r\n<*Answer_6570*>| 5. In the last month, how often have you felt that things w
ere going your way?| <*Answer_6571*>| 6. In the last month, how often have you found that you could not \r\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. \r\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 a
ngered because of things that were outside of \r\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*>|
| \r\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 \r\nused in conjunction with
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{"id":105,"instrument":201,"template":".| .| Restless Legs Syndrome Rating Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
\r\n<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | RLS Score: <-RLS->| | | Scoring:| Mild (1 - 10)| Moderate (11 - 20)| \r\n Severe (21 - 30)| Very sev
ere (31 - 40) | | Questions and Answers| | 1. Overall, how would you rate the RLS discomfort in your legs or arms?| <*Answer_6664*>| 2. Overall, how \r\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?| \r\n<*Answer_6666*>| 4. How severe was your sleep disturbance due to your RLS symptoms?| <*Answer_6667*>|
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5. How severe was your tiredness or sleepiness during the day due to your RLS \r\nsymptoms?| <*Answer_6668*>| 6. How severe was your RLS as a whole?| <*Answer_6669*>| 7. How often did you get RLS symptoms?| <*Answer_66
70*>| 8. When you had RLS symptoms, how \r\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 \r\
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 \r\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 \r\nshould be verified for accuracy and used in conjunction with other diagnostic
activities and procedures.| $~"},"rule":[{"booleanOperator":"AND","consistencyCheck":null,"id":262,"indexOperator":"Equals","indexQuestionId":6664,"indexValue":0,"indexValueDataType":"STRING","instrumentId":201,"instrumentQuestionId":
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0,"questionDisplay":89134,"questionId":7242,"questionText":"How alert do you feel after the first half hour after having awakened in the morning?","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":50},{"choice":[{"
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please check one response that best describes you. ","max":0,"min":0,"questionDisplay":89150,"questionId":7250,"questionText":"How long a time does it usually take before you \"recover your senses\" in the morning after rising from a nigh
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Evening Type: 22 and less| Intermediate Type: 23 - 43| \r\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 en
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tirely free to plan your day?| \r\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 \r\ncirc
umstances, 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. \r\nDuring the first half hour after having a
wakened 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 \r\nthis one hour twice a week and the best time for him is 7:00-8:00 am. Bearing i
n mind nothing else but your \"feeling best\" rhythm, how do you think you would perform? | <*Answer_7244*>| 7. At \r\nwhat time in the evening do you feel tired and as a result, in need of sleep?| <*Answer_7245*>| 8. You wish to b
e at your peak performance for a test, which you know is going to be mentally \r\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 t
esting ti | <*Answer_7246*>| 9. One \r\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 \r\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 \r\ndoes it usually take bef
ore 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 \r\nindividual?| <*Answer_7251*>| | | Information containe
d in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be \r\nverified for accuracy and used in conjunction with other diagnostic activities and procedures.
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reasons or in doses other than prescribed. You will also be asked about illicit or illegal drug \r\nuse - but only to better diagnose and treat you. For each substance, select the appropriate frequency of use. For example, if you have us
tifierIen":40472,"choiceTypeId":49482,"designator":"1h.","hint":null,"id":6881,"instrument":207,"introDisplay":98138,"introId":2178,"introText":"1. In your Lifetime, which of the following substances have you ever used? | (Note: For prescri
ent":207,"template":".| .| Alcohol Smoking and Substance Involvement Screening - NIDA modified version| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: \r\n<.Patient_Name_Last_First.>| SSN:
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | ASSIST NIDA| Cannabis: <-Cannabis->| \r\nCocaine: <-Cocaine->| Prescription stimulants: <-Prescriptio
n stimulants->| Methamphetamine: <-Methamphetamine->| Inhalants: <-Inhalants->| Sedatives or \r\nsleeping pills: <-Sedatives or sleeping pills->| Hallucinogens: <-Hallucinogens->| Street Opi
oids: <-Street Opioids->| Prescription opioids: <-Prescription opioids->| \r\n Other: <-Other->| | | Level of risk associated with different substance involvement score ranges| for illicit or non
medical prescription drug use:| \r\n0 - 3 Lower risk| 4 - 26 Moderate risk| 27+ High risk| | | Questions and Answers| | 1. Alcohol (for men, 5 or more drinks a day o
r for women, 4 \r\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. \r\nCannabis (marijuana,
pot, grass, hash, etc.)| <*Answer_6929*>| 1b. Cocaine (coke, crack, etc.)| <*Answer_6930*>| 1c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet \r\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. \r\nSedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)| <*A
nswer_6934*>| 1g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)| \r\n<*Answer_6935*>| 1h. Street opioids (heroin, opium, etc.)| <*Answer_6936*>| 1i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percoce
t], hydrocodone [Vicodin], methadone, buprenorphine, \r\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
ption medications, please report nonmedical use only.) ","max":0,"min":0,"questionDisplay":98153,"questionId":6936,"questionText":
, etc.)?|
\r\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 \r\n(Ritalin, Dexedrine, Adderall, d
iet pills, etc.)?| <*Answer_6941*>| 2d. In the past three months, how often have you used methamphetamine (speed, crystal meth, etc.)?| <*Answer_6942*>| 2e. In \r\nthe past three months, how often have you used inhalants (nitrous ox
ide, gas, paint thinner, etc.)?| <*Answer_6943*>| 2f. In the past three months, how often have you used sedatives or sleeping \r\npills (Valium, Serepax, Ativan, Librium, Xanax, GHB, etc.)?| <*Answer_6944*>| 2g. In the past three mo
nths, how often have you used hallucinogens (LSD, acid, PCP, Special K, ecstasy, etc.)?| \r\n<*Answer_6945*>| 2h. In the past three months, how often have you used street opioids (heroin, opium, etc.)?| <*Answer_6946*>| 2i. In the p
ast three months, how often have you used prescription \r\nopioids (fentanyl, oxycodone, [OxyContin], hydrocodone [Vicodin],methadone, buprenorphine, etc.)?| <*Answer_6947*>| 2j. In the past three months, how often have you used other s
ubstances (as \r\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 \r\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 \r\nprescribed amphetamine type stimulants (Ritalin, Dexedr
ine, Adderall, diet pills, etc.)?| <*Answer_6951*>| 3d. In the past 3 months, how often have you had a strong desire or urge to use \r\nmethamphetamine (speed, crystal meth, etc.)?| <*Answer_6952*>| 3e. In the past 3 months, how oft
en have you had a strong desire or urge to use inhalants (nitrous oxide, gas, paint thinner, etc.)?| \r\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 (Vali
"Street opioids (heroin, opium, etc.)","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":150},{"choice":[{"choiceId":237,"choiceText":"No","ien":102406,"legacyValue":"N","sequence":1},{"choiceId":241,"choiceText":"
um, Serepax, Ativan, Librium, Xanax, GHB, etc.)?| \r\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. I
n the past 3 \r\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 \r\nuse prescribed opioid
s (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6957*>| 3j. In the past 3 months, how often have you had a strong desire \r\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, \r\nlegal or financial problems?| <*Answer_6959*>| 4b. During the past 3 months, how often ha
s your use of cocaine (coke, crack, etc.) led to health, social, legal or financial problems?| \r\n<*Answer_6960*>| 4c. During the past 3 months, how often has your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adde
rall, diet pills, etc.) led to health, social, legal or \r\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 financ
ial problems?| \r\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*>|
\r\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?| \r\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?| \r\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 \r\npast 3 months, how often has your use of prescribed opioids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methado
Yes","ien":102407,"legacyValue":"Y","sequence":2}],"choiceDisplay":98156,"choiceIdentifier":0,"choiceIdentifierIen":40473,"choiceTypeId":49483,"designator":"1i.","hint":null,"id":6882,"instrument":207,"introDisplay":98138,"introId":2178,"in
ne, buprenorphine, etc.) led to health, social, legal or financial \r\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?| \r\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.)?| \r\n<*Answer_6969*>| 5b. During t
he 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 \r\nthe past 3 months, how often have you failed to do what was normall
y expected of you because of your use of prescribed amphetamine type stimulants (Ritalin, Dexedrine, Adderall, diet pills, etc.)? | \r\n <*Answer_6971*>| 5d. During the past 3 months, how often have you failed to do what was normally exp
ected of you because of your use of methamphetamine (speed, crystal meth etc.)?| \r\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 (nitr
ous oxide, gas, paint thinner, etc.)?| \r\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, Lib
rium, \r\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 \r\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.)?| \r\n <*Answer_6976*>| 5i. During the past 3 months, how often ha
ve you failed to do what was normally expected of you because of your use of prescribed opioids (fentanyl, oxycodone [OxyContin], \r\nhydrocodone [Vicodin], methadone, buprenorphine, etc.)? | <*Answer_6977*>| 5j. During the past 3 mont
hs, how often have you failed to do what was normally expected of you because of your use of \r\nother substances (as specified above)?| <*Answer_7171*>| 6a. Has a friend or relative or anyone else ever expressed concern about your use
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of cannabis (marijuana, pot, grass, hash, etc.)?| \r\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 \r\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 \r\nexpressed concer
n 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 \r\n(nitrous oxide, gas, paint thinner, etc.)?| <*Answ
er_6983*>| 6f. Has a friend or relative or anyone else ever expressed concern about your use of sedatives or sleeping pills (Valium, Serepax,
\r\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.)?| \r\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 \r\nanyone else ever expressed concern about your use of prescribed opio
ids (fentanyl, oxycodone [OxyContin], hydrocodone [Vicodin], methadone, buprenorphine, etc.)?| <*Answer_6987*>| 6j. Has a friend \r\nor relative or anyone else ever expressed concern about your use of other substances (as specified abov
e)?| <*Answer_7172*>| 7a. Have you ever tried and failed to control, cut down or stop using \r\ncannabis (marijuana, pot, grass, hash, etc.)?| <*Answer_6989*>| 7b. Have you ever tried and failed to control, cut down or stop using co
caine (coke, crack, etc.)?| <*Answer_6990*>| 7c. Have \r\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. Ha
ve you ever tried and \r\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 \r\noxide, gas,
scription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)","required":false,"responseTypeId":1,"responseTypeText":"MCHOICE","sequence":160},{"choice":[{"choiceId":237,"choiceText":"
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, \r\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 \r\ntried and failed to control, cut down or stop using street opioids (heroin, opium, et
c.)?| <*Answer_6996*>| 7i. Have you ever tried and failed to control, cut down or stop using prescribed opioids \r\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 \r\n(as specified above)?| <*Answer_7173*>| 8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)?| <*Answer_6999*>| | | Information containe
d in this note is based on a self-report \r\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.
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ument":215,"template":".| .| 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.>| \r\nDOB: <.Patient
ceId":230,"choiceText":"Daily or almost daily","ien":102454,"legacyValue":4,"sequence":5}],"choiceDisplay":98178,"choiceIdentifier":0,"choiceIdentifierIen":40483,"choiceTypeId":49493,"designator":"2i.","hint":null,"id":6892,"instrument":207
_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\r\nand 12-13\/psychosis )indicate the ne
ed for additional assessment.| | | Domain Results | | Domain Screening Results| |\r\n I. Depression...................................<*Answer_7771*>| II. Anger.....
...................................<*Answer_7772*>| III. Mania........................................<*Answer_7773*>|\r\n IV. Anxiety......................................<*Answer_7774*>| V. Somatic Symptoms.................
............<*Answer_7775*>| VI. Suicidal Ideation............................<*Answer_7776*>|\r\n VII. Psychosis....................................<*Answer_7777*>| VIII. Sleep Problems...............................<*Answer_77
78*>| IX. Memory.......................................<*Answer_7779*>|\r\n X. Repetitive Thoughts and Behaviors............<*Answer_7780*>| XI. Dissociation.................................<*Answer_7781*>|\r\n XII. Pers
onality Functioning......................<*Answer_7782*>| XIII. Substance Use................................<*Answer_7783*>|
\r\n| Questions and Answers| | 1. Little interest or pleasure in doing things?| <*Answer_7216*>| 2. Feeling down, depressed, \r\nor hopeless?| <*Answer_7217*>| 3. Feeling more irritated, grouchy, or angry than usual?| <*Answer_7
218*>| 4. Sleeping less than usual, but still have a lot of energy?| <*Answer_7219*>| 5. \r\nStarting lots more projects than usual or doing more risky things than usual?| <*Answer_7220*>| 6. Feeling nervous, anxious, frightened, wo
rried, or on edge?| <*Answer_7221*>| 7. Feeling \r\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)?| \r\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 \r\npeople couldnt hear,
,"introDisplay":98138,"introId":2178,"introText":"1. In your Lifetime, which of the following substances have you ever used? | (Note: For prescription medications, please report nonmedical use only.) ","max":0,"min":0,"questionDisplay":981
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?| \r\n<*Answer_7228*>| 14. Problems with sleep that affected yo
ur sleep quality over all?| <*Answer_7229*>| 15. Problems with memory (e.g., learning new information) or with location (e.g., finding way \r\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 \r\nover again?| <*Answer_7232*>| 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your mem
ories?| <*Answer_7233*>| 19. Not knowing who you really are or \r\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 le
ast 4 drinks of any kind of \r\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 \r\nOWN, t
hat is, without a doctors prescription, in greater amounts or longer than prescribed: painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like \r\nsleeping pills or Valium), or drugs marijuana, co
caine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or meth (like speed)? | \r\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 \r\npatients.| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnosti
c purposes. Assessment results should be verified for accuracy \r\nand used in conjunction with other diagnostic activities and procedures.| $~"},"scaleGroup":[{"grid1":0,"grid2":0,"grid3":0,"id":241,"instrument":215,"name":"CCSA-DSM5","o
rdInc":1,"ordMax":15,"ordMin":0,"ordTitle":"Score","scale":[{"groupId":241,"id":972,"name":"Depression","scoringKey":[{"id":8931,"questionId":7216,"scaleId":972,"targetText":"None\/not at all","value":0},{"id":8932,"questionId":7216,"scaleI
|
