Step 1 of 8 12% Part -I Substances and Drug Use HistoryAlcohol Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Methamphetamine Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Amphetamine Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Methadone Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Cocaine Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Cannabis Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Spice Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Heroin Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Other opiates Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Hallucinogens Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Tranquilizers Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Mushrooms Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Inhalants Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Other (please specify) Method of Use? (I.V., snorting Smoking oral)Age of first use?How often did you use initially?How much did you use initially?How often did you use in the past 12 months?How much did you use in the past month or in the 12 months?Age of heaviest use?How often did you use in your heaviest use?How much did you use during your heaviest use?Date of last use? DD slash MM slash YYYY Part -II University of Rhode Island Change Assessment (URICA) ScaleName(Required)Date(Required) DD slash MM slash YYYY There are FIVE possible responses: 1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree 1. As far as I'm concerned, I don't have any problems that need changing(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 2. I think I might be ready for some self-improvement.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 3. I am doing something about the problems that had been bothering me.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 4. It might be worthwhile to work on my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 5. I'm not the problem one. It doesn't make much sense for me to be here.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 6. It worries me that I might slip back on a problem I have already changed, so I am here to seek help.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 7. I am finally doing some work on my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 8. I've been thinking that I might want to change something about myself.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 9. I have been successful in working on my problem, but I'm not sure I can keep up the effort on my own.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 10. At times my problem is difficult, but I'm working on it.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 11. Being here is pretty much of a waste of time for me because the problem doesn't have to do with me.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 12. I'm hoping this place will help me to better understand myself.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 13. I guess I have faults, but there's nothing that I really need to change.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 14. I am really working hard to change.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 15. I have a problem and I really think I should work on it.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 16. I'm not following through with what I had already changed as well as I had hoped, and I'm here to prevent a relapse of the problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 17. Even though I'm not always successful in changing, I am at least working on my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 18. I thought once I had resolved the problem I would be free of it, but sometimes I still find myself struggling with.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 19. I wish I had more ideas on how to solve my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 20. I have started working on my problems but I would like help.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 21. Maybe this place will be able to help me.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 22. I may need a boost right now to help me maintain the changes I've already made. Strongly Disagree Disagree Undecided Agree Strongly Agree 23. I may be part of the problem, but I don't really think I am.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 24. I hope that someone here will have some good advice for me.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 25. Anyone can talk about changing; I'm actually doing something about it.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 26. All this talk about psychology is boring. Why can't people just forget about their problems?.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 27. I 'm here to prevent myself from having a relapse of my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 28. I t is frustrating, but I feel I might be having a recurrence of a problem I thought I had resolved.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 29. I have worries but so does the next guy. Why spend time thinking about them?(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 30. I am actively working on my problem.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 31. I would rather cope with my faults then try to change them.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree 32. After all I had done to try and change my problem, every now and again it comes back to haunt me.(Required) Strongly Disagree Disagree Undecided Agree Strongly Agree Part -III Adverse Childhood Experience (ACE) QuestionnaireWhile you were growing up, during your first 18 years of life:1. Did a parent or other adult in the household often... Swear at you, insult you, put you down, or humiliate you?:Act in a way that made you afraid that you might be physically hurt?(Required) Yes No 2. Did a parent or other adult in the household often... Push, grab, slap, or throw something at you?:Ever hit you so hard that you had marks or were injured?(Required) Yes No 3. Did an adult or person at least 5 years older than you ever.. Touch or fondle you or have you touch their body in a sexual way?Try to or actually have oral, anal, or vaginal sex with you?(Required) Yes No 4. Did you often feel that... No one in your family loved you or thought you were important or special?Your family didn't look out for each other, feel close to each other, or support each other?(Required) Yes No 5. Did you often feel that... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?(Required) Yes No 6. Were your parents ever separated or divorced?(Required) Yes No 7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her?Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?(Required) Yes No Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?(Required) Yes No 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?(Required) Yes No 9. Was a household member depressed or mentally ill or did a household member attempt suicide?(Required) Yes No 10. Did a household member go to prison?(Required) Yes No Drug Screening Questionnaire (DAST) Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.Patient name:(Required)Date of birth(Required) DD slash MM slash YYYY How often have you used these drugs?(Required) Monthly or less Weekly Daily or almost daily 1. Have you used drugs other than those required for medical reasons?(Required) Yes No 2. Do you abuse more than one drug at a time?(Required) Yes No 3. Are you unable to stop using drugs when you want to?(Required) Yes No 4. Have you ever had blackouts or flashbacks as a result of drug use?(Required) Yes No 5. Do you ever feel bad or guilty about your drug use?(Required) Yes No 6. Does your spouse (or parents) ever complain about your involvement with drugs?(Required) Yes No 7. Have you neglected your family because of your use of drugs?(Required) Yes No 8. Have you engaged in illegal activities in order to obtain drugs?(Required) Yes No 9. Have you ever experienced withdrawal symptoms (felt sick) when you No stopped taking drugs?(Required) Yes No 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?(Required) Yes No Have you ever injected drugs?(Required) Never Yes, in the past 90 days Yes, more than 90 days ago Have you ever been in treatment for substance abuse?(Required) Never Currently In the past Part -IV General Anxiety Disorder (GAD-7)Over the last 2 weeks, how often have you been bothered by any of the following problems?Feeling nervous, anxious, or on edge(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Not being able to stop or control worrying(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Worrying too much about different things(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Trouble relaxing(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Being so restless that it's hard to sit still(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Becoming easily annoyed or Irritable(Required) Not at Sure Several Days Over Half The Days Nearly Every Day Feeling afraid as if something awful might happen(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people(Required) Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult Part -V PATIENT HEALTH QUESTIONNAIRE-91. Over the last 2 weeks, how often have you been bothered by the following problems?1. Little interest or pleasure in doing things(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 2. Feeling down, depressed, or hopeless.(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 3. Trouble falling or staying asleep, or sleeping too much.(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 4. Feeling tired or having little energy.(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 5. Poor appetite or overeating.(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 7. Trouble concentrating on things, such as reading the newspaper or watching television(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless ced2 Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual(Required) Not at Sure Several Days Over Half The Days Nearly Every Day 9. Thoughts that you would be better off dead or of hurting yourself in some way(Required) Not at Sure Several Days Over Half The Days Nearly Every Day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?(Required) Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult Part -VI SHORT Michigan Alcohol Screening Test (SMAST)NAME(Required)Date(Required) DD slash MM slash YYYY Please answer every question. If you have difficulty with a countyment, then choose the response that is mostly right.1. Do you feel that you are a normal drinker? (by normal we mean do you drink less than or as much as most other people.)(Required) Yes No 2. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?(Required) Yes No 3. Do you ever feel guilty about your drinking?(Required) Yes No 4. Do friends or relatives think you are a normal drinker?(Required) Yes No 5. Are you able to stop drinking when you want to?(Required) Yes No 6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?(Required) Yes No 7. Has your drinking ever created problems between you and your wife, husband, a parent or other near relative?(Required) Yes No 8. Have you ever gotten into trouble at work because of your drinking?(Required) Yes No 9. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?(Required) Yes No 10. Have you ever gone to anyone for help about your drinking?(Required) Yes No 11. Have you ever been in a hospital because of drinking?(Required) Yes No 12. Have you ever been arrested for drunken driving, driving while intoxicated, or driving under the influence of alcoholic beverages?(Required) Yes No 13. Have you ever been arrested, even for a few hours, because of other drunken behaviors?(Required) Yes No Part -VII South Oaks Gambling ScreenName(Required)Date(Required) DD slash MM slash YYYY 1. Please indicate which of the following types of gambling you have done. For each type, mark one answer which describes the last time you performed each listed behavior and how often you did the behavior. If you check "Not at all" each listed behavior and how often you did the behavior If vou check "Not simply go on to the next item as you will not need to report "how often".Did any kind of gambling (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Did any kind of gambling (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played cards for money (such as Texas Hold'em, poker, or other card games)(When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played cards for money (such as Texas Hold'em, poker, or other card games)(How often?)(Required) Less then one time per week One to two times per week Three or more times per week Bet on horses, dogs, or other animals (at OTB, the track or with a bookie) for money (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Bet on horses, dogs, or other animals (at OTB, the track or with a bookie) for money (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Bet on sports for money (including basketball, football, parlay cards, Jai Alai, or other sports) with friends, a bookie, at work, etc. (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Bet on sports for money (including basketball, football, parlay cards, Jai Alai, or other sports) with friends, a bookie, at work, etc. (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played dice games (including craps, over and under, or other dice games) for money (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played dice games (including craps, over and under, or other dice games) for money (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Gambled in a casino or on a casino boat (legal or otherwise) for money (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Gambled in a casino or on a casino boat (legal or otherwise) for money (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played the numbers or bet on lotteries, Kino, or Quick Draw (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played the numbers or bet on lotteries, Kino, or Quick Draw (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played bingo for money (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played bingo for money (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played the stock, options, and /or commodities market (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played the stock, options, and /or commodities market (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Played slot machines, poker machines, or other gambling machines (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Played slot machines, poker machines, or other gambling machines (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Bowled, shot pool, played golf or darts, or some other game of skill for money (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Bowled, shot pool, played golf or darts, or some other game of skill for money (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Pull tabs or "paper" games other than lotteries (such as Lucky 7's) (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Pull tabs or "paper" games other than lotteries (such as Lucky 7's) (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Some form of gambling not listed above (please specify) (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Some form of gambling not listed above (please specify) (How often?)(Required) Less then one time per week One to two times per week Three or more times per week Gambled and used alcohol or drugs at the same time (When you did the behavior)(Required) Not at all More then one year ago Less then one year ago In the past six months Gambled and used alcohol or drugs at the same time (How often?)(Required) Less then one time per week One to two times per week Three or more times per week 2. How troubled or bothered have you been, due to your gambling, in the past six months? (Circle one)(Required) Not at all Slightly Moderately Considerably Extremely 3. Have you ever quit gambling for a period or time?(Required) I have never gambled No, I have never quit Yes, more than one year ago to today Yes, more than six months but less than one year ago to today Yes, in the past six months to today Yes, in the past month to today Yes, in the past week to today 4. What is the largest amount of money you have ever gambled on any one day?(Required) Never have gambled More than $100 up to $1,000 $1 or less More than $1,000 up to $10,000 More than $1 up to $10 More than $10,000 More than $10 up to $100 5a. Check which of the following people in your life has (or had) a gambling problem.(Required) Father Mother A brother or sister A grandparent My spouse or partner My child (ren) Another relative A friend or someone else important in my life 5b. Have your family members ever been criticized about their gambling?(Required) Yes No 6. When you gamble, how often do you go back another day to win back money you lost?(Required) I do not or have not ever gambled Never $1 or less Some of the time (less than half the time I lost) Most of the time I lost Every time I lost 7. Do you feel you have had a problem with betting money or gambling?(Required) No Yes, in the past but not now Yes 7a. If you answered yes to item seven, how long ago did you have a problem betting?(Required) More than one year ago Less than one year ago In the past six months In the past month In the past week 8. Have you ever claimed to be winning money gambling but weren't really? In fact, you lost?(Required) I have never gambled Never Yes, less than half the time I lost Yes, most of the time Please circle "yes" or "no" for each of the following statements as they describe you.9. Did you ever gamble more than you intended to?(Required) Yes No 10. Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?(Required) Yes No 11. Have you ever felt guilty about the way you gamble or what happens when you gamble?(Required) Yes No 12. Have you ever felt like you would like to stop betting money or gambling but didn't think you could?(Required) Yes No 13. Have you ever hidden betting slips, lottery tickets, gambling money, 1.O.U.'s or other signs of(Required) Yes No 14. Have you ever argued with people you live with over how you handle money?(Required) Yes No 15. (If you answered yes to question 14): Have money arguments ever centered on your gambling?(Required) Yes No 16. Have you ever lost time from work or school due to betting money or gambling?(Required) Yes No 17. Have you ever borrowed from someone and not paid them back as a result of your gambling?(Required) Yes No 18. If you borrowed money to gamble or to pay gambling debts., who or where did you borrow from? (circle "yes" or "no" for each)a. From household money(Required) Yes No b. From your spouse or parents(Required) Yes No c. From other relatives, friends, boyfriends or girlfriends, or in-laws(Required) Yes No d. From banks, loan companies, or credit unions(Required) Yes No e. From credit cards or debit cards(Required) Yes No f. From loan sharks(Required) Yes No g. You cashed in stock, bonds, or other securities(Required) Yes No h. You sold personal or family property(Required) Yes No i. You borrowed from your checking (you passed bad checks)(Required) Yes No j. You have (had) a credit line with a bookie(Required) Yes No k.You have (had) a credit line with a casino(Required) Yes No
