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  • ASI 5th Ed PDF

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    ASI_5th_Ed.pdf

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    23 Ansichten6 Seiten

    ASI 5th Ed PDF

    Hochgeladen von

    drmss

    Copyright:

    © All Rights Reserved
    Als PDF herunterladen oder online auf Scribd lesen
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    von 6
    INSTRUCTIONS 1. Lzave No Bank - Where appropriate code items: esi not anmvered jeston not aplictble Use only one characte per item 2. tom numbers circled ar to be asked at fllow- up. Hes wih an ater ae curative and ould be rephrased at follow-up (see Mara) 3. Space is provided ater sctons for addtional ‘The severity stings are interviewer estimates ofthe patients need fr additonal reatmentin tach aes, The seales range from 0 (no teat ment necessary) to 9 (teatment needed to Intervene in life-threatening situation). Each rating is based upon the patient's history of problem symptoms, resentconditionandsub- Jestve assesment of his treatment needs in & fivensrea, Fore detailed description of sever fy ratings derivation procedures and conven- tions, see mana. Note: These Severity ratings are optional. ifth Eition/J998 Version SUMMARY OF PATIENTS RATING SCALE, 0-Notat ll, 1 Slightly 2 Moderately 3. Considerably 4 Extremely G1. LD. NUMBER GENERAL INFORMATION NAME ca.rasraprorrs oF ss CURRENT ADDRESS. G21, Shipley C.Q. ©», mooramwuwper — ] on supny 0 4, pare oF : Ge DATE G13, apocRaPac cone 3, Best Ta Sere G14, How ong hve you G5. DATE OF lived at this address? a ata INTERVIEW TE OE G15 Isthis esis nad 300 G6. TIME BEGUN ‘or your family? hom O-No1-¥ee cos 7. Tage ENDED ie, DATEOF ae om, G8. CLASS: ry oI RACE TsIntake Lt 1 - White (Not of Hispenic Origin) oe, 2- Follow-up 2- Black (Not of Hispanic Origin) 5: Ameria ian —| a Alscmn Nate os, conracr cope 3 Anan: te ide _— I inFesn se ance 2 mone 4 lun -Pao Ran 2 pene “Catan 9 Or Bian 3 @ a __| ote, neticious rRarenence : 1M CL] ret 4c “rene eeoe™ (ches s Slewin” 6Nowe a on, mrexviewer ve you btn in contol 7 coDE NUMBER oka te nae Soe a 1Ne i 12, EIA: al : et mina 3 Aloo or Drag Teement 2 patented 4 Meta eam 3 tin ont spond phi Tete ale —— Elgislg g ow ny day? alals] slg] 2|sle BIER S/S 1ale ADDITIONAL TEST RESULTS +B) How many times in your lie have you been hospitalized for mee! problems? (include 0.4", d's, exclude deter) M2. How fong ago was your last hospitalization fora piysical problem ™ MB. Do you have any chron medical problems which continue to inter- Fece with your lif? 0-No 1 Yes Specity ‘MEDICAL STATUS. Do you receive a pension fora physical disability? Bxefude pyehlanie disability) 0-No TYE, ‘Spey How many days have you experienced medical problems inthe past 30? FOR QUESTIONS M7 & M8 PLEASE ASK PATIENT TO USE THE PATIENTS RATING SCALE How troubled or bothered have Are you taking any prescribed medication ona regular basi, you been by these medical problems inthe past 30 days? How important fo you now i treatment for these medical problems? ‘VIERVIEWER SEVERITY RATING M9, How would you rate the patients need for medical treatment? Is the above information significantly distorted by: Patients misrepresentation? T= Yes Patient's inability to understand? © fora bys problem? O-No t= Yee OFNo Yer Comments ‘EMELOYMENT/SUPPORT STATUS “( Education completed Jsual employment pattern, iow many people depend on Qari he) Lair! 20 tm epiomaton © wore epoorte 7 : 1 Rl ie 0 ae) Food abel ee? Teningo techie 2 patie hin) eduction compte : Spurting nee daywost) Eid) How many days bv you 3, Doyou ive po 0s 4 dent cxpenenessempioyment [| Do you hse rofsion, ceria problemen the past 307 oa re 6 etre isaitty ty 7- unemployed FOR QUESTIONS £20 & E21 PLEASE ASK te 8 in controlled environment PATIENT TO USE THE PATIENT'S Spey RATING SCALE Ho many days were you paid te eee for working in he past 30? (20) sow woubied or bothered Have rd tcl ert se ost) ou eon by tne eps 0-No problems inthe past 30 days? ow mach money did you esive fom he eee following sources inthe past 30 days? Howe important to you nw is (ansmer Noo vai drive's lense) ossing oto ployment O-No1-Yes @ emo Lier) 6, How long vas your a longest full-time job? ompenda Jow would you rate the patient's he A comnention E22, How woud you ste the ps Does someone contibute to your support in any way’? realy ie aaay OnNo I= Yes © gore macs s ve oes this constitute the majority of your support? O-No I= Yes Qu 2) Pension beets Smiley GD ve, iyo antne portonal expenses). © ies need for employment counseling? CONFIDENCE RATINGS Js the shove information significantly distorted by: Patients misrepreentation? ‘O-No 1 Yee Patient’ inability to understand? © ‘O-No” I Yee PAST 30. LIFETIME USE Das Ys Rtof a, lesbo Any Alcohol = To Intoxication sbetanee por day (nel. aleoboy "Noto: Soe manual for representative examples for each drug class * Route of Administration: 1 = Oral, 2= Nasel 3=Smoking, 4= Non IV inj, 5=1V i DRUG/ALCOHOL USE Whit substance is the major problem? Please code ar ‘ove or O0-No problem; 15-Aleohol & Drug (Dual addiction), 16-Polydrus; ‘when nor elear, ask paren DIS. How tong was your last period of voluntary abstinence from this major substance? (00- naver abstinent) 16, How many months ago i thie abstinence en? (00- sil abstinent) ‘low many times have you How many times in your life have you been reste fr: How many ofthese were detox only? -@oma How much would you say you spent

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