Addiction Severity Index Exam

Addiction Severity Index INTRODUCING THE ASI: Seven potential problem areas: Medical, Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and Psychological. All clients receive the same standard interview. All information gathered is confidential. LIST OF COMMONLY USED DRUGS: Alcohol: Beer, wine, liquor Methadone: Dolophine, LAAM Opiates: Painkillers = Morphine; Dilaudid; Demerol; Percocet; Darvon; Talwin; Codeine; Tylenol 2, 3, 4 Barbiturates: Nembutal, Seconal, Tuinol, Amytal, Pentobarbital, Secobarbital, Phenobarbital, Fiorinol Sedatives/ Hypnotics/ Tranquilizers Benzodiazepines, Valium, Librium, Ativan, Serax Tranxene, Dalmane, Halcion, Xanax, Miltown Chloral Hydrate (Noctex), Quaaludes Cocaine: Cocaine Crystal, Freebase Cocaine or “Crack,” and ”Rock Cocaine” Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin, Preludin, Methamphetamine, Speed, Ice, Crystal Cannabis Marijuana, Hashish Hallucinogens: LSD (Acid), Mescaline, Mushrooms (Psilocybin), Peyote, Green, PCP (Phencyclidine), Angel Dust, Ecstasy Inhalants: Nitrous Oxide, Amyl Nitrate (Whippets, Poppers), Glue, Solvents, Gasoline, Toluene, etc. We will discuss two time periods: 1. The past 30 days 2. Lifetime data Patient Rating Scale: Patient input is important. For each area, I will ask you to use this scale to let me know how bothered you have been by any problems in each section. I will also ask you how important treatment is for you in the area being discussed. The scale is: 0–Not at all 1–Slightly 2–Moderately 3–Considerably 4–Extremely If you are uncomfortable giving an answer, then don’t answer. Please do not give inaccurate information! Remember: This is an interview, not a test. INTERVIEWER INSTRUCTIONS: 1. Leave no blanks. 2. Make plenty of comments and include the question number before each comment. If another person reads this ASI, that person should have a relatively complete picture of the client’s perceptions of his or her problems. 3. X = Question not answered. N = Question not applicable. 4. Stop the interview if the client misrepresents two or more sections. 5. Tutorial and coding notes are preceded by •. INTERVIEWER SCALE: 0–1 2–3 4–5 6–7 8–9 = = = = = No problem Slight problem Moderate problem Severe problem Extreme problem HALF TIME RULE: If a question asks for the number of months, round up periods of 14 days or more to 1 month. Round up 6 months or more to 1 year. CONFIDENCE RATINGS: • Last two items in each section. • Do not overinterpret. • Denial does not warrant misrepresentation. • Misrepresentation is overt contradiction in information. PROBE AND MAKE PLENTY OF COMMENTS! Just note if these are used: Antidepressants Ulcer Medications—Zantac, Tagamet Asthma Medications—Ventoline Inhaler, Theo-Dur Other Medications—Antipsychotics, Lithium ALCOHOL/DRUG USE INSTRUCTIONS: This section looks at two time periods: the past 30 days and years of regular use, or lifetime use. Lifetime use refers to the time prior to the past 30 days. • 30-day questions require only the number of days used. • Lifetime use is asked to determine extended periods of regular use. It refers to the time prior to the past 30 days. • Regular use = 3+ times per week, 2+ day binges, or problematic, irregular use in which normal activities are compromised. • Alcohol to intoxication does not necessarily mean “drunk”; use the words “felt the effects,” “got a buzz,” “high,” etc. instead of “intoxication.” As a rule of thumb, 5+ drinks in one day, or 3+ drinks in a sitting defines intoxication. • How to ask these questions:  How many days in the past 30 days have you used…?  How many years in your life have you regularly used…? GENERAL INFORMATION ADDITIONAL TEST RESULTS G1. ID No.: – G2. Soc. Sec. No.: / G4. Date of Admission: / G5. Date of Interview: – G21. _____________________________ / G22. _____________________________ G23. _____________________________ G24. _____________________________ G25. _____________________________ G26. _____________________________ G27. _____________________________ G28. _____________________________ (Month/Day/Year) / (Month/Day/Year) G6. Time Begun: (Hour:Minutes) : G7. Time Ended: (Hour:Minutes) : G8. Class: 1. Intake 2. Follow-up G9. Contact Code: 1. In person 2. Telephone (Intake ASI must be in person) G10. Gender: 1. Male 2. Female SEVERITY PROFILE G11. Interviewer Code No./Initials: PROBLEMS G12. Special: 1. 2. 3. N. Patient terminated Patient refused Patient unable to respond Not applicable 0 1 2 3 4 5 6 7 8 9 MEDICAL EMP/SUPPORT ALCOHOL DRUGS __________________________________________________ Name LEGAL FAMILY/SOCIAL __________________________________________________ PSYCH. Address 1 __________________________________________________ Address 2 GENERAL INFORMATION COMMENTS (Include the question number with your notes) __________________________________________________ City State Zip Code / (Years/Months) G14. How long have you lived at this address? __________________________________________________ __________________________________________________ __________________________________________________ G15. Is this residence owned by you or your family? 0–No 1–Yes __________________________________________________ / G16. Date of birth: / __________________________________________________ (Month/Day/Year) G17. Of what race do you consider yourself? __________________________________________________ 1. White (not Hispanic) 4. Alaskan Native 7. Hispanic-Puerto Rican 2. Black (not Hispanic) 5. Asian/Pacific Islander 8. Hispanic-Cuban 3. American Indian 6. Hispanic-Mexican 9. Other Hispanic __________________________________________________ G18. Do you have a religious preference? 1. Protestant 3. Jewish 2. Catholic 4. Islamic __________________________________________________ 5. Other 6. None __________________________________________________ G19. Have you been in a controlled environment in the past 30 days? __________________________________________________ 1. No 4. Medical Treatment 2. Jail 5. Psychiatric Treatment 3. Alcohol/Drug Treatment 6. Other: ______________ • A place, theoretically, without access to drugs/alcohol. G20. How many days? • “NN” if Question G19 is No. Refers to total number of days detained in the past 30 days. __________________________________________________ __________________________________________________ MEDICAL STATUS Confidence Rating Is the above information significantly distorted by: M1. How many times in your life have you been hospitalized for medical problems? • Include ODs and DTs. Exclude detox, alcohol/drug, psychiatric treatment, and childbirth (if no complications). Enter the number of overnight hospitalizations for medical problems. M2. How long ago was your last hospitalization for a physical problem? • If no hospitalizations in Question M1, then this should be “NN.” M10.Patient’s misrepresentation? 0–No 1–Yes M11. Patient’s inability to understand? 0–No 1–Yes / (Years/Months) ______________________________________________ M3. Do you have any chronic medical problems that continue to interfere with your life? 0–No 1–Yes • If Yes, specify in comments. • A chronic medical condition is a serious physical condition that requires regular care (i.e., medication, dietary restriction), preventing full advantage of the person’s abilities. ______________________________________________ ______________________________________________ ______________________________________________ M15. Number of months pregnant: • “N” for males, “0” for not pregnant. MEDICAL COMMENTS (Include question number with your notes) (Months) M4. Are you taking any prescribed medication on a regular basis for a physical problem? 0–No 1–Yes • If Yes, specify in comments. • Medication prescribed by an M.D. for medical conditions; not psychiatric medicines. Include medicines prescribed whether or not the patient is currently taking them. The intent is to verify chronic medical problems. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ M5. Do you receive a pension for a physical disability? 0–No 1–Yes • If Yes, specify in comments. • Include worker’s compensation; exclude psychiatric disability. M6. How many days have you experienced medical problems in the past 30 days? • Include flu, colds, etc. Include serious ailments related to drugs/alcohol, which would continue even if the patient were abstinent (e.g., cirrhosis of liver, abscesses from needles). ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ For Questions M7 & M8, ask the patient to use the Patient’s Rating Scale. M7. How troubled or bothered have you been by these medical problems in the past 30 days? (Restrict response to problem days of Question M6.) M8. How important to you now is treatment for these medical problems? • If client is currently receiving medical treatment, refer to the need for additional medical treatment by the patient. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Interviewer Severity Rating M9. How would you rate the patient’s need for medical treatment? • Refers to the patient’s need for additional medical treatment. ______________________________________________ ______________________________________________ EMPLOYMENT/SUPPORT STATUS • GED = 12 years, note in comments. • Include formal education only. EMPLOYMENT/SUPPORT COMMENTS / E1. Education completed: (Include question number with your notes) (Years/Months) ______________________________________________ E2. Training or technical education completed: • Formal/organized training only. For military training, include only training that can be used in civilian life (e.g., electronics, artillery). (Months) ______________________________________________ ______________________________________________ ______________________________________________ E3. Do you have a profession, trade, or skill? 0–No 1–Yes • Employable, transferable skill acquired through training. • If Yes, specify _________________________________ ______________________________________________ ______________________________________________ ______________________________________________ E4. Do you have a valid driver’s license? ______________________________________________ • Valid license; not suspended/revoked. 0–No 1–Yes E5. Do you have an automobile available for use? ______________________________________________ • If answer to E4 is No, then E5 must be No. 0–No 1–Yes Does not require ownership, requires only availability on a regular basis. ______________________________________________ ______________________________________________ / E6. How long was your longest full-time job? • Full time = 40+ hours weekly; does not necessarily mean most recent job. ______________________________________________ (Years/Months) ______________________________________________ E7. Usual (or last) occupation? (specify) ___________________________________ ______________________________________________ (Use Hollingshead Categories Reference Sheet) ______________________________________________ ______________________________________________ E8. Does someone contribute to your support in any way? 0–No 1–Yes • Is patient receiving any regular support (i.e., cash, food, housing) from family/friend? Include spouse’s contribution; exclude support by an institution. ______________________________________________ ______________________________________________ ______________________________________________ E9. Does this constitute the majority of your support? 0–No 1–Yes • If E8 is No, then E9 is N. ______________________________________________ ______________________________________________ ______________________________________________ E10. Usual employment pattern, past 3 years? 1. Full time (40 hrs/week) 5. Service/Military 2. Part time (regular hours) 6. Retired/Disability 3. Part time (irregular hours) 7. Unemployed 4. Student 8. In controlled environment • Answer should represent the majority of the last 3 years, not just the most recent selection. If there are equal times for more than one category, select that which best represents the current situation. ______________________________________________ ______________________________________________ ______________________________________________ EMPLOYMENT/SUPPORT (cont.) E11. How many days were you paid for working in the past 30 days? • Include “under the table” work, paid sick days, and vacation. Interviewer Severity Rating E22. How would you rate the patient’s need for employment counseling? For Questions E12–17: How much money did you receive from the following sources in the past 30 days? E12. Employment • Net or “take home” pay; include any “under the table” money. Confidence Rating Is the above information significantly distorted by: E23. Patient’s misrepresentation? 0–No 1–Yes E24. Patient’s inability to understand? 0–No 1–Yes E13. Unemployment compensation E14. Welfare • Include food stamps, transportation money provided by an agency to go to and from treatment. E15. Pensions, benefits, or Social Security • Include disability, pensions, retirement, veteran’s benefits, SSI, and worker’s compensation. EMPLOYMENT/SUPPORT COMMENTS (cont.) (Include question number with your notes) ______________________________________________ ______________________________________________ ______________________________________________ E16. Mate, family, or friends • Money for personal expenses (e.g., clothing); include unreliable sources of income. Record cash payments only; include windfalls (unexpected), money from loans, legal gambling, inheritance, tax returns, etc. E17. Illegal • Cash obtained from drug dealing, stealing, fencing stolen goods, illegal gambling, prostitution, etc. Do not attempt to convert drugs exchanged to a dollar value. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ E18. How many people depend on you for the majority of their food, shelter, etc.? • Must be regularly depending on patient; do include alimony/child support; do not include the patient or self-supporting spouse, etc. E19. How many days have you experienced employment problems in the past 30 days? • Include inability to find work, if actively looking for work, or problems with present job in which that job is jeopardized. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ For Questions E20 & E21, ask the patient to use the Patient’s Rating Scale. E20. How troubled or bothered have you been by these employment problems in the past 30 days? • If the patient has been incarcerated or detained during the past 30 days, he or she cannot have employment problems. In that case, an N response is indicated. E21. How important to you now is counseling for these employment problems? • Stress help in finding or preparing for a job, not giving the patient a job. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ALCOHOL/DRUGS Route of administration: ALCOHOL/DRUGS COMMENTS 1. Oral 2. Nasal 3. Smoking 4. Non-IV injection 5. IV injection • Note the usual or most recent route. For more than one route, choose the most severe. The routes are listed from least severe to most severe. Years of Route of Past 30 Days Regular Use Admin. (Include question number with your notes) ______________________________________________ ______________________________________________ ______________________________________________ D1. Alcohol (any use at all) ______________________________________________ D2. Alcohol (to intoxication) ______________________________________________ D3. Heroin ______________________________________________ D4. Methadone ______________________________________________ D5. Other Opiates/Analgesics D6. Barbiturates ______________________________________________ D7. Sedatives/Hypnotics/Tranquilizers ______________________________________________ D8. Cocaine ______________________________________________ D9. Amphetamines ______________________________________________ D10. Cannabis D11. Hallucinogens ______________________________________________ D12. Inhalants ______________________________________________ D13. More than one substance per day (including alcohol) ______________________________________________ ______________________________________________ D14. According to the interviewer, which substance(s) is/are the major problem? ______________________________________________ • Interviewer should determine the major drug of abuse. Code the number next to the drug in Questions D1–12, or “00” = no problem, “15” = alcohol and one or more drugs, “16” = more than one drug but no alcohol. Ask patient when not clear. ______________________________________________ ______________________________________________ ______________________________________________ D15. How long was your last period of voluntary abstinence from this major substance? • Last attempt of at least 1 month, not necessarily the longest. Periods of hospitalization/incarceration do not count. Periods of Antabuse, methadone, or naltrexone use during abstinence do count. • “00” = never abstinent (Months) D16. How many months ago did this abstinence end? • If D15 = “00,” then D16 = “NN.” • “00” = still abstinent. How many times have you: D17. Had alcohol DTs? • Delirium Tremens (DTs): Occur 24-48 hours after last drink or significant decrease in alcohol intake; includes shaking, severe disorientation, fever, hallucinations. DTs usually require medical attention. D18. Overdosed on drugs? • Overdoses (OD): Requires intervention by someone to recover, not simply sleeping it off; include suicide attempts by OD. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ALCOHOL/DRUGS (cont.) How many times in your life have you been treated for: D19. Alcohol abuse? D20. Drug abuse? • Include detoxification, halfway houses, in/outpatient counseling, and AA or NA (if 3+ meetings within 1-month period). How many of these were detox only? Interviewer Severity Rating How would you rate the patient’s need for treatment for: D32. Alcohol problems? D33. Drug problems? D21. Alcohol Confidence Rating Is the above information significantly distorted by: D22. Drugs D34. Patient’s misrepresentation? 0–No 1–Yes • If D19 = “00,” then Question D21 is “NN.” If D20 = “00,” then Question D22 is “NN.” How much money would you say you spent during the past 30 days on: D35. Patient’s inability to understand? 0–No 1–Yes ALCOHOL/DRUGS COMMENTS (cont.) (Include question number with your notes) D23. Alcohol? ______________________________________________ D24. Drugs? ______________________________________________ • Count only actual money spent. What is the financial burden caused by drugs/alcohol? D25. How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days? • Include AA/NA D99. How many days have you been treated in an inpatient setting for alcohol or drugs in the past 30 days? ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ How many days in the past 30 days have you experienced: ______________________________________________ D26. Alcohol problems? ______________________________________________ D27. Drug problems? • Include: Craving, withdrawal symptoms, disturbing effects of use, or wanting to stop and being unable to. ______________________________________________ ______________________________________________ For Questions D28-D31, ask the patient to use the Patient’s Rating Scale. The patient is rating the need for additional substance abuse treatment. How troubled or bothered have you been in the past 30 days by these: ______________________________________________ ______________________________________________ ______________________________________________ D28. Alcohol problems? ______________________________________________ D29. Drug problems? ______________________________________________ How important to you now is treatment for: ______________________________________________ D30. Alcohol problems? ______________________________________________ D31. Drug problems? LEGAL STATUS L24. Are you presently awaiting charges, trial, or sentencing? 0–No 1–Yes L1. Was this admission prompted or suggested by the criminal justice system? 0–No 1–Yes • Judge, probation/parole officer, etc. L25. What for? • Use the number of the type of crime committed: L3–16 and L18–20. • Refers to Question L24. If more than one charge, choose the most severe. L2. Are you on parole or probation? 0–No 1–Yes • Note duration and level in comments. How many times in your life have you been arrested and charged with the following: L26. How many days in the past 30 days were you detained or incarcerated? L3. Shoplifting/Vandalism L10. Assault L4. Parole/Probation Violations L11. Arson L5. Drug Charges L12. Rape L6. Forgery L13. Homicide/ Manslaughter L7. Weapons Offense L14. Prostitution ______________________________________________ L8. Burglary/Larceny/ Breaking and Entering L15. Contempt of Court ______________________________________________ L9. Robbery L16. Other: ______ • Include being arrested and released on the same day. LEGAL COMMENTS (Include question number with your notes) • Include total number of counts, not just convictions. Do not include juvenile (pre age 18) crimes, unless client was charged as an adult. • Include formal charges only. ______________________________________________ ______________________________________________ ______________________________________________ L17. How many of these charges resulted in convictions? ______________________________________________ • If L3–16 = 00, then question L17 = “NN.” • Do not include misdemeanor offenses from questions L18–20 below. • Convictions include fines, probation, incarcerations, suspended sentences, guilty pleas, and plea bargaining. ______________________________________________ ______________________________________________ How many times in your life have you been charged with the following: L18. Disorderly conduct, vagrancy, public intoxication? ______________________________________________ ______________________________________________ L19. Driving while intoxicated? ______________________________________________ L20. Major driving violations? ______________________________________________ • Moving violations: speeding, reckless driving, no license, etc. ______________________________________________ ______________________________________________ L21. How many months have you been incarcerated in your life? ______________________________________________ • If incarcerated 2 weeks or more, round this up to 1 month. List total number of months incarcerated. L22. How long was your last incarceration? • Enter “NN” if never incarcerated. L23. What was it for? • Use codes L3–16, L18–20. If multiple charges, choose the most severe. Enter “NN” if never incarcerated. ______________________________________________ (Months)i ______________________________________________ ______________________________________________ LEGAL STATUS (cont.) LEGAL COMMENTS (cont.) L27. How many days in the past 30 days have you engaged in illegal activities for profit? (Include question number with your notes) • Exclude simple drug possession. Include drug dealing, prostitution, selling stolen goods, etc. May be cross-checked with Question E17 under Employment/Support Section. ______________________________________________ ______________________________________________ For Questions L28-29, ask the patient to use the Patient’s Rating Scale. L28. How serious do you feel your present legal problems are? ______________________________________________ ______________________________________________ • Exclude civil problems L29. How important to you now is counseling or referral for these legal problems? • Patient is rating a need for additional referral to legal counsel for defense against criminal charges. Interviewer Severity Rating L30. How would you rate the patient’s need for legal services or counseling? ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ Confidence Rating Is the above information significantly distorted by: L31. Patient’s misrepresentation? 0–No 1–Yes ______________________________________________ L32. Patient’s inability to understand? 0–No 1–Yes ______________________________________________ FAMILY HISTORY Have any of your blood-related relatives had what you would call a significant drinking, drug use, or psychiatric problem? Specifically, was there a problem that did or should have led to treatment? Mother’s Side Alcohol Drug Psych. Father’s Side Alcohol Drug Psych. Siblings H1. Grandmother H6. Grandmother H11. Brother H2. Grandfather H7. Grandfather H12. Sister H3. Mother H8. Father H4. Aunt H9. Aunt H5. Uncle H10. Uncle Alcohol Drug Psych. 0 = Clearly No for any relatives in that category X = Uncertain or don’t know 1 = Clearly Yes for any relatives in that category N = Never had a relative in that category • In cases in which there is more than one person for a category, report the most severe. Accept the patient’s judgment on these questions. FAMILY HISTORY COMMENTS (Include question number with your notes) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ FAMILY/SOCIAL RELATIONSHIPS F1. Marital Status: 1–Married 3–Widowed 5–Divorced 2–Remarried 4–Separated 6–Never Married • Code common-law marriage as “1” and specify in comments. F2. How long have you been in this marital status (Question F1)? / (Years/Months) Would you say you have had a close, long-lasting, personal relationship with any of the following people in your life: F12. Mother F15. Sexual partner/ spouse F13. Father F16. Children F14. Brothers/ sisters F17. Friends • If never married, then since age 18. F3. Are you satisfied with this situation? 0–No 1–Indifferent 2–Yes • Satisfied = generally liking the situation. • Refers to Questions F1 and F2. 0 = Clearly No for all in class X = Uncertain or “I don’t know” 1 = Clearly Yes for any in class N = Never had a relative in category F4. Usual living arrangements (past 3 years): 1–With sexual partner and children 6–With friends 2–With sexual partner alone 7–Alone 3–With children alone 8–Controlled environment 4–With parents 9–No stable arrangement 5–With family • Choose arrangements most representative of the past 3 years. If there is an even split in time between these arrangements, choose the most recent arrangement. F5. How long have you lived in these arrangements? / FAMILY/SOCIAL COMMENTS (Include question number with your notes) ______________________________________________ ______________________________________________ ______________________________________________ (Years/Months) • If with parents or family, since age 18. • Code years and months living in arrangements from Question F4. ______________________________________________ ______________________________________________ F6. Are you satisfied with these arrangements? ______________________________________________ 0–No 1–Indifferent 2–Yes ______________________________________________ Do you live with anyone who: F7. Has a current alcohol problem? 0–No 1–Yes F8. Uses nonprescribed drugs, or abuses prescribed drugs? 0–No 1–Yes ______________________________________________ ______________________________________________ ______________________________________________ F9. With whom do you spend most of your free time? 1–Family 2–Friends 3–Alone • If a girlfriend/boyfriend is considered as family by patient, then the patient must refer to that person as “family” throughout this section, not as a friend. F10. Are you satisfied with spending your free time this way? 0–No 1–Indifferent 2–Yes • A satisfied response must indicate that the person generally likes the situation. Refers to Question F9. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ F11. How many close friends do you have? • Stress that you mean close. Exclude family members. These are “reciprocal” relationships or mutually supportive relationships. ______________________________________________ ______________________________________________ FAMILY/SOCIAL (cont.) Have you had significant periods in which you have experienced serious problems getting along with: 0–No 1–Yes Past 30 days Interviewer Severity Rating In Your Life F18. Mother F19. Father F36. How would you rate the patient’s need for family and/or social counseling? Confidence Rating Is the above information significantly distorted by: F20. Brother/sister F37. Patient’s misrepresentation? 0–No 1–Yes F21. Sexual partner/spouse F38. Patient’s inability to understand? 0–No 1–Yes F22. Children FAMILY/SOCIAL COMMENTS (cont.) F23. Other significant family (specify) _____________________ (Include question number with your notes) F24. Close friends ______________________________________________ F25. Neighbors ______________________________________________ F26. Coworkers ______________________________________________ • “Serious problems” mean those that endangered the relationship. • A “problem” requires contact of some sort, either by telephone or in person. ______________________________________________ ______________________________________________ ______________________________________________ Has anyone ever abused you? 0–No 1–Yes Past 30 days In Your Life F27. Emotionally • Made you feel bad through harsh words. F28. Physically • Caused you physical harm. F29. Sexually • Forced sexual advances/acts. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ How many days in the past 30 days have you had serious conflicts with: ______________________________________________ F30. Your family? ______________________________________________ F31. Other people (excluding family)? ______________________________________________ For Questions F32–35, ask the patient to use the Patient’s Rating Scale. ______________________________________________ How troubled or bothered have you been in the past 30 days by: ______________________________________________ F32. Family problems? ______________________________________________ F33. Social problems? ______________________________________________ How important to you now is treatment or counseling for: F34. Family problems • Patient is rating his or her need for counseling for family problems, not whether the patient would be willing to attend. F35. Social problems • Include patient’s need to seek treatment for such social problems as loneliness, inability to socialize, and dissatisfaction with friends. Patient rating should refer to dissatisfaction, conflicts, or other serious problems. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ PSYCHIATRIC STATUS How many times have you been treated for any psychological or emotional problems: For Questions P13–P14, ask the patient to use the Patient’s Rating Scale. P1. In a hospital or inpatient setting? P13. How much have you been troubled or bothered by these psychological or emotional problems in the past 30 days? P2. Outpatient/private patient? • Do not include substance abuse, employment, or family counseling. Treatment episode = a series of more or less continuous visits or treatment days, not the number of visits or treatment days. • Enter diagnosis in comments if known. P3. Do you receive a pension for a psychiatric disability? 0–No 1–Yes • Patient should be rating the problem days from Question P12. P14. How important to you now is treatment for these psychological or emotional problems? PSYCHIATRIC STATUS COMMENTS (Include question number with your comments) Have you had a significant period of time (that was not a direct result of alcohol/drug use) in which you have: 0–No 1–Yes Past 30 days In Your Life ______________________________________________ P4. Experienced serious depression, sadness, hopelessness, loss of interest, difficulty with daily functioning? ______________________________________________ P5. Experienced serious anxiety/tension— were uptight, unreasonably worried, unable to feel relaxed? P6. Experienced hallucinations—saw things or heard voices that others didn’t see/hear? P7. Experienced trouble understanding, concentrating, or remembering? P8. Experienced trouble controlling violent behavior, including episodes of rage or violence? ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ • Patient can be under the influence of alcohol/drugs. ______________________________________________ P9. Experienced serious thoughts of suicide? • Patient seriously considered a plan for taking his or her life. Patient can be under the influence of alcohol/drugs. P10. Attempted suicide? • Include actual suicidal gestures or attempts. • Patient can be under the influence of alcohol/drugs. ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ P11. Been prescribed medication for any psychological or emotional problems? • Prescribed for the patient by a physician. Record “Yes” if a medication was prescribed even if the patient is not taking it. ______________________________________________ ______________________________________________ ______________________________________________ P12. How many days in the past 30 days have you experienced these psychological or emotional problems? • This refers to problems noted in Questions P4–P10. ______________________________________________ ______________________________________________ PSYCHIATRIC STATUS (cont.) The following items are to be completed by the interviewer: PSYCHIATRIC STATUS COMMENTS (cont.) (Include question number with your notes) At the time of the interview, the patient was: 0–No 1–Yes ______________________________________________ P15. Obviously depressed/withdrawn ______________________________________________ P16. Obviously hostile ______________________________________________ P17. Obviously anxious/nervous ______________________________________________ P18. Having trouble with reality testing, thought disorders, paranoid thinking P19. Having trouble comprehending, concentrating, remembering ______________________________________________ ______________________________________________ ______________________________________________ P20. Having suicidal thoughts ______________________________________________ Interviewer Severity Rating P21. How would you rate the patient’s need for psychiatric/psychological treatment? Confidence Rating Is the above information significantly distorted by: P22. Patient’s misrepresentation? 0–No 1–Yes P23. Patient’s inability to understand? 0–No 1–Yes ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________