Addiction Severity Index Lite - CF

Clinical/Training Version

Thomas McLellan, Ph.D. HOLLINGSHEAD CATEGORIES:

John Cacciola, Ph.D. 1. Higher execs, major professionals, owners of large businesses.
2. Business managers if medium sized businesses, lesser professions, i.e.,
Deni Carise, Ph.D. nurses, opticians, pharmacists, social workers, teachers.
Thomas H. Coyne, MSW 3. Administrative personnel, managers, minor professionals,
Remember: This is an interview, not a test owners/proprietors of small businesses, i.e., bakery, car dealership,
engraving business, plumbing business, florist, decorator, actor, reporter,
≈Item numbers circled are to be asked at follow-up.≈ travel agent.
≈Items with an asterisk* are cumulative and should be 4. Clerical and sales, technicians, small businesses (bank teller, bookkeeper,
rephrased at follow-up.≈ clerk, draftsman, timekeeper, secretary).
≈Items in a double border gray box are questions for the interviewer. 5. Skilled manual - usually having had training (baker, barber, brakeman,
Do not ask these questions of the client.≈
chef, electrician, fireman, lineman, machinist, mechanic, paperhanger,
painter, repairman, tailor, welder, policeman, plumber).
6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook,
INTRODUCING THE ASI: Seven potential problem areas: Medical, drill press, garage guard, checker, waiter, spot welder, machine operator).
Employment/Support Status, Alcohol, Drug, Legal, Family/Social, and 7. Unskilled (attendant, janitor, construction helper, unspecified labor,
Psychological. All clients receive this same standard interview. All porter, including unemployed).
information gathered is confidential. 8. Homemaker.
There are two time periods we will discuss: 9. Student, disabled, no occupation.
1. The past 30 days
2. Lifetime Data
LIST OF COMMONLY USED DRUGS:
Patient Rating Scale: Patient input is important. For each area, I will ask Alcohol: Beer, wine, liquor
you to use this scale to let me know how bothered you have been by any Methadone: Dolophine, LAAM
problems in each section. I will also ask you how important treatment is for Opiates: Pain killers = Morphine, Dilaudid, Demerol,
you for the area being discussed. Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4,
The scale is: 0 - Not at all Syrups = Robitussin, Fentanyl
1 - Slightly Barbiturates: Nembutal, Seconal, Tuinal, Amytal, Pentobarbital,
2 - Moderately Secobarbital, Phenobarbital, Fiorinal
3 - Considerably Sed/Hyp/Tranq: Benzodiazepines = Valium, Librium, Ativan, Serax
Tranxene, Dalmane, Halcion, Xanax, Miltown,
4 - Extremely Other = Chloral Hydrate, Quaaludes
If you are uncomfortable giving an answer, then don't answer. Cocaine: Cocaine Crystal, Free-Base Cocaine or Crack, and
Please do not give inaccurate information! "Rock Cocaine"
Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin,
Preludin, Methamphetamine, Speed, Ice, Crystal
Cannabis: Marijuana, Hashish
INTERVIEWER INSTRUCTIONS: Hallucinogens: LSD (Acid), Mescaline, Psilocybin (Mushrooms), Peyote,
1. Leave no blanks. Green, PCP (Phencyclidine), Angel Dust, Ecstacy
2. Make plenty of Comments (if another person reads this ASI, they should Inhalants: Nitrous Oxide (Whippits), Amyl Nitrite (Poppers),
have a relatively complete picture of the client's perceptions ofhis/her Glue, Solvents, Gasoline, Toluene, Etc.
problems).
Just note if these are used: Antidepressants,
3. X = Question not answered.
Ulcer Meds = Zantac, Tagamet
N = Question not applicable. Asthma Meds = Ventolin Inhaler, Theodur
4. Terminate interview if client misrepresents two or more sections. Other Meds = Antipsychotics, Lithium
5. When noting comments, please write the question number.
6. Tutorial/clarification notes are preceded with "•".
ALCOHOL/DRUG USE INSTRUCTIONS:
The following questions look at two time periods: the past 30 days and lifetime.
HALF TIME RULE: If a question asks the number of months,
Lifetime refers to the time prior to the last 30 days. However if the client has been
round up periods of 14 days or more to 1 incarcerated for more than 1 year, you would only gather lifetime information, unless
month. Round up 6 months or more to 1 the client admits to significant alcohol /drug use during incarceration. This guideline
year. only applies to the Alcohol/Drug Section.
30 day questions only require the number of days used.
CONFIDENCE RATINGS: Last two items in each section. Lifetime use is asked to determine extended periods of use.
Do not over interpret. Regular use = 3+ times per week, binges, or problematic irregular use
Denial does not warrant in which normal activities are compromised.
Alcohol to intoxication does not necessarily mean "drunk", use the
misrepresentation.
words felt the effects", “got a buzz”, “high”, etc. instead of intoxication.
Misrepresentation = overt contradiction in As a rule of thumb, 5+ drinks in one setting, or within a brief period of
information. time defines “intoxication".
Probe and make plenty of comments! “How to ask these questions:
→ "How many days in the past 30 have you used....?
→ "How many years in your life have you regularly used....?"

Revised- 06/02/99 DC/TRJ

Addiction Severity Index Lite - Training Version
GENERAL INFORMATION
__________________________________________________
G1.ID No.: Name

__________________________________________________
G2. SS No. : - - Address 1

__________________________________________________
G3. Program No: ___ ____ ____ Address 2

______________________________________(____)______
G4. Date of Admission: / / City State Zip Code Tel. No.

G5. Date of Interview: / / G14. How long have you lived at this
address? Years Months

G8. Class: 1. Intake 2. Follow-up

G16. Date of birth: / /
(Month/Day/Year)

G17. Of what race do you consider yourself?

1. White (not Hisp) 5. Asian/Pacific 9. Other Hispanic
G9. Contact Code: 1. In person 2. Black (not Hisp) 6. Hispanic-Mexican
2. Telephone (Intake ASI must be in person) 3. American Indian 7. Hispanic-Puerto Rican
3. Mail 4. Alaskan Native 8. Hispanic-Cuban

G18. Do you have a religious preference?

G10. Gender: 1. Male 2. Female 1. Protestant 3. Jewish 5. Other
2. Catholic 4. Islamic 6. None

G19. Have you been in a controlled environment in

G11. Interviewer Code No.: the past 30 days?
1. No 4. Medical Treatment
2. Jail 5. Psychiatric Treatment
3. Alcohol/Drug Treat. 6. Other: ______________
•A place, theoretically, without access to drugs/alcohol.
G12. Special: 1. Patient terminated
2. Patient refused
3. Patient unable to respond G20. How many days?
•"NN" if Question G19 is No. Refers to total
number of days detained in the past 30 days.

(Clinical/Training Version)
MEDICAL STATUS MEDICAL COMMENTS
(Include question number with your notes)
M1.∗ How many times in your life have you been
hospitalized for medical problems? __________________________________________________
• Include O.D.'s and D.T.'s. Exclude detox, alcohol/drug,
psychiatric treatment and childbirth (if no complications). Enter the __________________________________________________
number of overnight hospitalizations for medical problems.

__________________________________________________

M3. Do you have any chronic medical __________________________________________________

problems which 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 their abilities.
__________________________________________________

M4. Are you taking any prescribed __________________________________________________

medication on a regular basis 0 - No 1 - Yes
for a physical problem? __________________________________________________
• If Yes, specify in comments.
• Medication prescribed by a MD 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 Workers' compensation, exclude psychiatric disability.

__________________________________________________
M6. How many days have you experienced
medical problems in the past 30 days? __________________________________________________
• Do not include ailments directly caused by drugs/alcohol.
• 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, etc.).
__________________________________________________
For Questions M7 & M8, ask the patient to use the Patient 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? __________________________________________________
• Refers to the need for new or additional medical treatment by the patient.
__________________________________________________

__________________________________________________
CONFIDENCE RATINGS
Is the above information significantly distorted by:
__________________________________________________
M10. Patient's misrepresentation? 0 - No 1 - Yes
__________________________________________________
M11. Patient's inability to understand? 0 - No 1 - Yes
__________________________________________________

page 2
EMPLOYMENT/SUPPORT STATUS
E1.∗ Education completed: EMPLOYMENT/SUPPORT COMMENTS
• GED = 12 years, note in comments. (Include question number with your notes)
• Include formal education only. Years Months
__________________________________________________

E2.∗ Training or Technical education completed: __________________________________________________

• Formal/organized training only. For military training,
only include training that can be used in civilian life, Months
i.e., electronics or computers. __________________________________________________

__________________________________________________
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? __________________________________________________

• If answer to E4 is "No", then E5 must be "No". 0 - No 1 - Yes
Does not require ownership, only requires
availability on a regular basis. __________________________________________________

__________________________________________________
E6. How long was your longest full time job?
• Full time = 35+ hours weekly; __________________________________________________
does not necessarily mean most /
recent job. Yrs / Mos
__________________________________________________

__________________________________________________
E7.∗ Usual (or last) occupation?
(specify) ______________________________ __________________________________________________
(use Hollingshead Categories Reference Sheet)

__________________________________________________

E9 Does someone contribute the majority of __________________________________________________

your support? 0 - No 1 - Yes
__________________________________________________

__________________________________________________
E10. Usual employment pattern, past three years?
1. Full time (35+ hours) 5. Service
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 more current situation. __________________________________________________

__________________________________________________
E11. How many days were you paid for working
in the past 30 days? __________________________________________________
• Include "under the table" work, paid sick days and vacation.

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________
Page 3
EMPLOYMENT/SUPPORT (cont.)
How much money did you receive from
For questions E12-17: EMPLOYMENT/SUPPORT COMMENTS
(Include question number with your notes)
the following sources in the past 30 days?

E12. Employment? __________________________________________________

• Net or "take home" pay, include any
"under the table" money. __________________________________________________
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 & workers' compensation.
__________________________________________________
E16. Mate, family, or friends?
• Money for personal expenses, (i.e.
clothing), include unreliable sources of income __________________________________________________
(e.g. gambling). Record cash payments only,
include windfalls (unexpected), money from
loans, gambling, inheritance, tax returns, etc.). __________________________________________________
E17. Illegal? __________________________________________________
•Cash obtained from drug dealing,
stealing, fencing stolen goods, 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 ? __________________________________________________
• Include inability to find work, if they are actively looking for work,
or problems with present job in which that job is jeopardized.
__________________________________________________
For Question E20, ask the patient to use the Patient 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, they cannot have employment problems.
__________________________________________________
E21. How important to you now is counseling for
__________________________________________________
these employment problems?
• The patient's ratings in Questions E20-21 refer to Question E19.
• Stress help in finding or preparing for a job, not giving them a job. __________________________________________________

__________________________________________________
CONFIDENCE RATINGS
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 __________________________________________________

__________________________________________________

__________________________________________________
Page 4
ALCOHOL/DRUGS ALCOHOL/DRUGS COMMENTS
(Include question number with your notes)
Route of Administration Types:
1. Oral 2. Nasal 3. Smoking 4. Non-IV injection 5. IV
• 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.
Lifetime Route of __________________________________________________
Past 30 Days (years) Admin

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 1 substance __________________________________________________
per day (including alcohol)
__________________________________________________
D17. How many times have you had Alcohol DT's?
• Delirium Tremens (DT's): Occur 24-48 hours after last drink, or
significant decrease in alcohol intake, shaking, severe disorientation, __________________________________________________
fever, , hallucinations, they usually require medical attention. Page 5
ALCOHOL/DRUGS (cont.)
ALCOHOL/DRUGS COMMENTS
How many times in your life have you been treated for : (Include question number with your notes)
∗
D19 . Alcohol abuse?
__________________________________________________
D20∗. Drug abuse?
__________________________________________________
• Include detoxification, halfway houses, in/outpatient counseling,
and AA or NA (if 3+ meetings within one month period).
__________________________________________________
How many of these were detox only:
D21. Alcohol? __________________________________________________

D22. Drugs? __________________________________________________

• 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: __________________________________________________
D23. Alcohol? __________________________________________________
D24. Drugs?
__________________________________________________
• Only count actual money spent. What is the financial burden caused by
drugs/alcohol?
__________________________________________________
D25. How many days have you been treated as
an outpatient for alcohol or drugs in the __________________________________________________
past 30 days? • Include AA/NA
__________________________________________________
For Questions D28-D31, ask the patient to use the Patient Rating scale.
The patient is rating the need for additional substance abuse treatment. __________________________________________________
How many days in the past 30 have you experienced:
__________________________________________________
D26. Alcohol problems?
How troubled or bothered have you been in the past 30 days by __________________________________________________
these
__________________________________________________
D28. Alcohol problems?
How important to you now is treatment for these: __________________________________________________

D30. Alcohol problems? __________________________________________________

How many days in the past 30 have you experienced:
__________________________________________________
D27. Drug problems?
• Include only: Craving, withdrawal symptoms,
disturbing effects of use, or wanting to stop and being unable to.
__________________________________________________
How troubled or bothered have you been in the past 30 days by
__________________________________________________
these

D29. Drug problems? __________________________________________________

How important to you now is treatment for these: __________________________________________________

D31. Drug problems?
__________________________________________________
CONFIDENCE RATINGS Page 6

Is the above information significantly distorted by:

D34. Patient's misrepresentation? 0-No 1-Yes

D35. Patient's inability to understand? 0-No 1-Yes

LEGAL STATUS
L1. Was this admission prompted or suggested by the LEGAL COMMENTS
(Include question number with your notes)
criminal justice system? 0 - No 1 -Yes
• Judge, probation/parole officer, etc.
__________________________________________________
L2. Are you on parole or probation?
• Note duration and level in comments. 0 - No 1 -Yes __________________________________________________

How many times in your life have you been arrested and __________________________________________________
charged with the following:
L3 ∗ Shoplift/Vandal ∗ Assault
L10∗ __________________________________________________
L4 ∗ Parole/Probation ∗ Arson
L11∗
__________________________________________________
L5 ∗ Drug Charges ∗ Rape
L12∗
__________________________________________________
L6 ∗ Forgery ∗ Homicide/Mansl.
L13∗
∗ Weapons Offense
L7∗ ∗ Prostitution
L14∗ __________________________________________________
∗ Burglary/Larceny/B&E
L8∗ ∗ Contempt of Court
L15∗
__________________________________________________
L9 ∗ Robbery ∗ Other: _________
L16∗
• Include total number of counts, not just convictions. Do not include __________________________________________________
juvenile (pre-age 18) crimes, unless they were charged as an adult.
• Include formal charges only.
__________________________________________________
∗
L17 How many of these charges resulted
in convictions? __________________________________________________
• If L03-16 = 00, then question L17 = "NN".
• Do not include misdemeanor offenses from questions L18-20 below. __________________________________________________
• Convictions include fines, probation, incarcerations, suspended
sentences, and guilty pleas.
__________________________________________________
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 were you incarcerated
in your life? __________________________________________________
• If incarcerated 2 weeks or more, round this up
to 1 month. List total number of months incarcerated. __________________________________________________

L24. Are you presently awaiting __________________________________________________

charges, trial, or sentence? 0 - No 1 - Yes
__________________________________________________
L25. What for?
• Use the number of the type of crime committed: 03-16
and 18-20
__________________________________________________
• Refers to Q. L24. If more than one, choose most severe.
• Don't include civil cases, unless a criminal offense is involved. __________________________________________________
L26. How many days in the past 30, were __________________________________________________
you detained or incarcerated?
• Include being arrested and released on the same day.
__________________________________________________

__________________________________________________
Page 7
LEGAL STATUS (cont.)
LEGAL COMMENTS
L27. How many days in the past 30 have (Include question number with your notes)
you engaged in illegal activities for profit?
• Exclude simple drug possession. Include drug dealing, prostitution,
selling stolen goods, etc. May be cross checked with Question E17
__________________________________________________
under Employment/Family Support Section.
__________________________________________________

__________________________________________________
For Questions L28-29, ask the patient to use the Patient 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. __________________________________________________

__________________________________________________
CONFIDENCE RATINGS
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
__________________________________________________

Page 8
FAMILY/SOCIAL RELATIONSHIPS FAMILY/SOCIAL COMMENTS
(Include question number with your notes)
F1. Marital Status:
1-Married 3-Widowed 5-Divorced
2-Remarried 4-Separated 6-Never Married __________________________________________________
• Common-law marriage = 1. Specify in comments.
__________________________________________________
F3. Are you satisfied with this situation?
0-No 1-Indifferent 2-Yes
• Satisfied = generally liking the situation. - Refers to Questions F1 & F2. __________________________________________________

F4.∗ Usual living arrangements (past 3 years): __________________________________________________

1-With sexual partner & 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.
__________________________________________________
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 non-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 they
must refer to them as family throughout this section, not 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. Referring to Question F9.
__________________________________________________
Have you had significant periods in which you have
experienced serious problems getting along with: __________________________________________________
0 - No 1 - Yes
Past 30 days In Your Life __________________________________________________
F18. Mother
F19. Father __________________________________________________

F20. Brother/Sister __________________________________________________

F21. Sexual Partner/Spouse
__________________________________________________
F22. Children
F23. Other Significant Family __________________________________________________
(specify)_________________________
__________________________________________________
F24. Close Friends
F25. Neighbors __________________________________________________
F26. Co-workers
• "Serious problems" mean those that endangered the relationship. __________________________________________________
• A "problem" requires contact of some sort, either by telephone or in person.
__________________________________________________
Did anyone abuse you? 0- No 1-Yes
Past 30 days In Your Life __________________________________________________
F28. Physically?
• Caused you physical harm. __________________________________________________
F29. Sexually? Page 9
• Forced sexual advances/acts.
FAMILY/SOCIAL (cont.) FAMILY/SOCIAL COMMENTS
(Include question number with your notes)

How many days in the past 30 have you had serious

conflicts: __________________________________________________

F30. With your family? __________________________________________________

For Questions F32-34, ask the patient to use the Patient Rating scale.
__________________________________________________
How troubled or bothered have you been in the past 30
days by:
__________________________________________________
F32. Family problems ?
__________________________________________________
FHow important to you now is treatment or counseling for
these:
__________________________________________________
F34. Family problems
• Patient is rating his/her need for counseling for family __________________________________________________
problems, not whether the family would be willing to attend.

How many days in the past 30 have you had serious __________________________________________________
conflicts:
__________________________________________________
F31. With other people (excluding family)?
For Questions F33-35, ask the patient to use the Patient Rating scale. __________________________________________________
How troubled or bothered have you been in the past 30
days by: __________________________________________________

F33. Social problems? __________________________________________________

How important to you now is treatment or counseling for __________________________________________________
these:
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.
__________________________________________________

__________________________________________________
CONFIDENCE RATING
Is the above information significantly distorted by: __________________________________________________
F37. Patient's misrepresentation? 0-No 1-Yes
__________________________________________________
F38. Patient's inability to understand? 0-No 1-Yes
__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________
Page 10
PSYCHIATRIC STATUS
How many times have you been treated for any
PSYCHIATRIC STATUS COMMENTS
psychological or emotional problems: (Include question number with your comments)
∗
P1. In a hospital or inpatient setting?
__________________________________________________
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
__________________________________________________
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 Lifetime __________________________________________________
P4. Experienced serious depression-
sadness, hopelessness, loss of __________________________________________________
interest, difficulty with daily function?
P5. Experienced serious anxiety/ tension, __________________________________________________
uptight, unreasonably worried,
inability to feel relaxed? __________________________________________________

P6. Experienced hallucinations-saw things __________________________________________________

or heard voices that were not there?
__________________________________________________
P7. Experienced trouble understanding,
concentrating, or remembering?
For Items P8-10, Patient can have been under the influence of alcohol/drugs. __________________________________________________
P8. Experienced trouble controlling violent behavior __________________________________________________
including episodes of rage, or violence?
P9. Experienced serious thoughts of suicide? __________________________________________________
• Patient seriously considered a plan for taking
his/her life. __________________________________________________
P10. Attempted suicide?
• Include actual suicidal gestures or attempts. __________________________________________________
P11. Been prescribed medication for any __________________________________________________
psychological or emotional problems?
• Prescribed for the patient by MD. Record "Yes" if a medication
was prescribed even if the patient is not taking it. __________________________________________________

P12. How many days in the past 30 have you experienced __________________________________________________
these psychological or emotional problems?
• This refers to problems noted in Questions P4-P10. __________________________________________________
For Questions P13-P14, ask the patient to use the Patient Rating scale
__________________________________________________
P13. How much have you been troubled or bothered by these
psychological or emotional problems in the past 30 days? __________________________________________________
• Patient should be rating the problem days from Question P12.

P14. How important to you now is treatment for __________________________________________________

these psychological or emotional problems?

CONFIDENCE RATING Page 11

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