AppenJix A.

Study Measures and Self-Report Questionnaires

- Alcohol Use Disorders Identification Test (AUDIT)
- Brief Addiction Monitor-Revised (BAM-R)
- Barratt Impulsiveness Scale-11 (BIS-11)
- Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A)
- Drug Abuse Screening Test (DAST-10)
- Insomnia Severity Index (ISI)
- Neurobehavioral Symptom Inventory (NSI)
- PTSD Checklist for DSM-5 (PCL-5)
- PEG Scale Assessing Pain Intensity and Interference (Pain, Enjoyment, General Activity)
- Penn State Cigarette Dependence Index
- Penn State Electronic Cigarette Dependence Index
- Patient Health Questionnaire (PHQ-9)
- Severson Smokeless Tobacco Dependence Scale
- Shepherd Center SHARE Military Initiative New Client Information Form
o Includes items from Alcohol Use Disorders Identification Test, Condensed (AUDIT-C),
Neurobehavioral Symptom Inventory (NSI), Single Question Drug Abuse Screening Test (DAS-
I), information on tobacco use and form of use for selecting future tobacco use assessment
measures
- Short Inventory of Problems Revised (SIP-R)
- University of Rhode Island Change Assessment Scale (URICA), Alcohol Version
- University of Rhode Island Change Assessment Scale (URICA), Drug Version
- World Health Organization Disability Assessment Schedule 2.0 (WI4ODAS 2.0)
 The Alcohol Use Disorders Identification Test(AUDIT}:Self-ReponVersion

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and
treatments, itis important that we ask some questions about your use of alcohol. Your answers will
remain confident ial so please be honest. Place an X in one box that best describes your answer to
each question.

Questions 0 1 2 3 4
1. How often do you have a drink 2-4times 4 or more
Monthly 2-3 flmes
containing alcohol? Never or less pr week times per
month week
2. How many drinks containing alcohol
do you have on a typical day when 1 or 2 3 or 4 5e 6 7to 9 10 or more
you are drinking?
3. How often do you have six or more Daily or
Less than
Neyer Monthly WeeMy almœt
drinks on one occasion7 Monthly
daily
4. How often during the last year have Daily or
Less than
you found that you were unable to Never Monthly Weeldy almœt
Monthly daily
stop drinking once you started?
5. How often during the last year have Daily or
Less than
you failed to do what was expected Never MoMhly Weeldy almœt
Monthly daily
of you because of drinking7
6. How often during the last year have
you needed a drink first thing in the Dally or
Less than
Never Monthly Weekly almœt
morning to getyourselfgoing after a Monthly daily
heavy drinking session*
7. How often during the last year have Daily or
Less than
you had a feeling ofguilt or remorse Never Monthly Monthly Weeldy alrnost
after drinking7 daily
8. How often during the last year have
Daily or
you been unable to remember what Never
Less than
Monthly Weekly almœt
happened the night before because Monthly
daily
you were drinking?
9. Have you or someone else been Yes,but Yes, during
injured because of your drinking? NO not in the the last
last year year
10. Has a relative, friend, doctor or other
Yes, but Yes, durfng
healthcare worker been concerned NO not in the the last
about your drinking or suggested vou last year year
cut down?
Total:
 Brief Addiction Monitor-Revised (BAM-R)

Name: Date:

This is a standard set of questions about several areas of your life such as your health, alcohol and drug use,
etc. The questions generally ash about fhe past 30 d'ays. Please consider each question and answer as
accurately as possible.

Method of Administration:
Clinician Interview Self Report Phone

1. In the past 30 days, how would you say your physical health has been?
0 Excellent (0)
0 Very Good (8)
0 Good (15)
0 Fair (22)
D Poor (30)

2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?

3. In the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the
day?

4. In the past 30 days, how many days did you drink ANY alcohol?

(If 00, Skip to #6)

5. In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a
woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce can/bottle of beer or 5-ounce glass
of wine.}

6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications?

(If 00, Skip to #8)

7. In the past 30 days, how many days did you use any of the following drugs:
7A. Marijuana (cannabis, pot, weed)?

7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?

7C. Cocaine and/or Crack?

7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?

7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin,
Fentanyl, etc.)?

7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)?

7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or
unknown medications)?
8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?
0 Not at all (0)
Slightly (8)
0 Moderately (15)
0 Considerably (22)
0 Extremely (30)

9. How confident are you that you will NOT use alcohol and drugs in the next 30 days?
D Not at all (0)
0 Slightly (8)
Moderately (15)
0 Considerably (22)
0 Extremely (30)

10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?

11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased
risk for using alcohol or drugs (i.e., around risky“people, places or things")?

J2. Does your religion or spirituality help support your recova .

Not at all (0)
0 Slightly (8)
0 Moderately (15)
Q Considerably (22)
0 Extremely (30)

13. In the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?

14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and
clothing for yourself and your dependents?
O No (0)
O Yes {30)

15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family
members or friends?
D Not at all (0)
D Slightly (8)
D Moderately (15)
D Considerably (22)
D Extremely (30)
16. In the past 30 days, how many days did you contact or spend time with any family members or friends who are
supportive of your recovery?

17. How satisfied are you with your progress toward achieving your recovery goals?
Q Not at all (0)
D Slightly (8)
D Moderately (15)
0 Considerably (22)
D Extremely (30)
DIRECTIONS: People difTer in the ways they act and think in different situations. This is a test
to measure some of the ways in which you act and think. Read each statement and put an X on
the appropriate circle on the right side of this page. Do not spend too much time on any
statement. Answer quickly and honestly.

RarelyfNever Occasionally Often Almost Always/Always

1 I plan tasks carefully.
@
2 I do things without thinking. @
3 I make-up my mind quickly. @
4 I am happy-go-lucky.
s I don't “pay attention.”
6 I have “racing” thoughts. @
7 I plan trips well ahead of time. @
8 I am self controlled. @
9 I concentrate easily. @
10 I save regularly. @
11 I “squirm” at plays or lectures. @
12 I am a careful thinker.
13 I plan for job security. @
14 I say things without thinking. @
15 I like to think about complex problems. @
16 I change jobs. @
17 I act “on impulse.” @
18 I get easily bored when solving thought problems. @
19 I act on the spur of the moment. @
20 I am a steady thinker. @
21 I change residences. @
22 I buy things on impulse. @
23 I can only think about one thing at a time. @
24 I change hobbies. @
25 I spend or charge more than I earn. @
26 I often have extraneous thoughts when thinking. @
27 I zxn more interested in the present than the future. @
28 I am restless at the theater or lectures. @
29 I like puzzles. @
30 I am future oriented. @
Paxoo, Stanford, Barratt (1995). I Cliy Pxy, vol. 51, pp. 768-774
 Behavior Rating
Invenory of
Executive Functiozï-
Adult Version

Robert M. Roth, PhD, Peter K. Isquith, PhD, and Gerard A. Gioia, PhD

On the followmg pagea is a list of statements. We would rike to know if you have had pmHgina
with they behaviors over the cast month. Please answer all the items the best that you can.
Please DO NOT SKIP ANY ITEMS. Indicate your response bx circling
N if the behavior is Never a problem
S if the behavior is Sometimes a Problem
O if the behavior is Often a problem

For example, if you never have trouble making decisions, you would circle N for this item:
I have trouble making decisions S O
Ifyou make a mistnke,or want to change your answer, DO NOT ERASE. Draw an “M through the
answer you want to change, and then circle the correct anawer:
I have trouble mnking decisions O
Before you begin answering the items, please fi11 in the name, gender, age, date of birth, today's
date, and years and level of education in the spaces provided at the top of the next page.

€3SR,• 16204 N. Florida Ave. • LuD, FL 33549 • 1.800.331.8378 www.parinc.com

Copyri@tO Ts96, 1998, 2¢b0, ztn1, 2ao, 2fKI4, 2tXI5 by PAUL AT ifg¥s userzat May rxXla «ymzxal ri whole or In parth anytxm or by any neerswigx›ut
written pemissbn of PAFL This form B piinted In red kik on ca/t›mbas japar. Any dler verslai b uaultoñzml.
9 8 7 6 5 43 2 \ Rexder gf¥M747
 Your Nt ne
Gender M lÏa1c D Fcniale Age Date of Birth Z
Years of Education: Lex ct of Education: O Less than High School O High Schuol O College
O It(aster’s degree O Doctorate O Other
During the past month, how often has each of the following behaviors been a problem?
N = Never S = Sometimes 0 = Often
1. I have angry oulbursls N S O
2. I nake carEless errors when completing tasks N S O
3. I am disoiganized N S 0
4. I have trouble concentrating on tasks (such as chores, reading, or z'ork) N S o
5. I tap my fingers or bounce my legs N S O
6. I need to be reminded to begin a task even when I ann willlng N S O
7. I have n messy ctoset N S O
8. I have trouble changing from one activity or task to another N S o
9. I get oveavhelmeö by Marge tasks N s O
10. I forget my name N S 0
11. I have trouble 'with jobs ol tasks that have more than one step N S 0
12. I overreacl emotionally N S o
13. I don't nolice when I cause others to feel bad or get mad until it is too late N S 0
14. I have troubTe getting ready for the day N S O
15. I have trouble grloritizing activities N S 0
16. I have trouble zitting slill N S 0
17. I lorgel whal I ann doing in the middte ol ttiings N S 0
18. I don't check my work for mistakes N S O
19. I have emotional outbursts for little reason N S 0
20. I lie arcund the house a lot N S 0
21. I start tasks (such as cooking, projecls) without the ‹ight matenals N S 0
22. I have tioubte accepting different ways to so!ve problems with work, friends, or tasks N S 0
23. I talk at the wrong time N S O
24. I misjudge ha '/ difficult or easy tasks will be N S O
2S. I have problems getting stailed on my Own N S O
26. I ha •e trouble staking on the same topic when lalking N S O
27. I gEt fired N S 0
28. I ‹each more emotionalty to situaüons than my friends N S o
29. I have problems waiting my tum N S o
30. People say tnat I arr disorganized N S O
31. I lose things (suCh as keys, money, wallet, homework, etc.) N S O
32. I have tiouble thinkin9 ° f ä different way to sotve a problem when stuck N S O
33. I overreact to small problems N S O
34. I don't plan ahead for future activities N S o
35. I have a short attention span N S 0
36. I make inapp›opriate sexual comments N S 0
37. When people seem upset iYith me, I don't understand why N S 0
38. I have tfouble ccunting to three N S 0
 During the past month, ho • often has each of the following behaviors been a problem?
N = Never S = Sometimes 0 = Often
39. I have unrealistic goals N S 0
%. lleavethe bahroonia mess N S 0
4T. I make careless mistakes N S 0
42. I get emotionally upset easily N S 0
43. I mnke decisions that get me into trouble (legally, iinan¢igl|y.socially) N S 0
44. I am L0thered by having to deal with changes N S 0
45. I have difficulty getting excited about things N S 0
‹6. I forget instructions east‹y N S 0
47. I have good ideas bul cannot get them on pape N S 0
48. I maka mistakes N S 0
49. I have troub!e getting started on tasks N S 0
50. I say things without thinking N S 0
51. My anger is intense but ends quickly N S 0
52. I have trouble finishing tasks (such as chokes, work) N S 0
53. I start things at the last minute (such as assignments, chores, tasks) N S 0
54. I ha ’e difficulty finishing a task on my own N S 0
55. People say that I am easily distracted N S 0
36. I have trouble remembering things, even for a few minutes (set as directions, phone numb°rs) M S 0
57. People say that I am too emotional N S 0
58. I ash through Kings N S 0
59. I get annoyed N S 0
60. I leave my room or home a mass N S 0
61. I gel disturbed by unexpected changes in my daily routine N S 0
62. I ha ’e trouble coming up vilh ideas for what to do with my free time N S O
63. I don't plan ahead for tasks N S o
54. People say that I don't think before acting N S 0
65. I have trouble linding things in my room, closet, or desk N S 0
66. I have problems organizing activities N S 0
67. After having a problem, I don't get over it easily N S 0
b8. I have trouble doing more than one thing at a time N S 0
69. My mood changes frequently N S 0
70. I don't think about consequences before doing something N S 0
71. I have trouble organizing work N S 0
72. I get upset quickly or easily over little things N S 0
73. I am impulsive N S 0
74. I don't pick up after myself N S 0
75. I have problems completing my soil N S 0
 Drug Abuse Screening Test, DAST-10
The following questions concern information about your possible involvement with drugs not including
alcoholic beverages during the past z2 months.

“Drug abuse” refers to ( ) the use of prescribed or over-the-counter drugs in excess of the directions,
and (z) any nonmedical use of drugs.

The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner),
tranquilizers (e.g„ Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics
(e.g., heroin). Remember that the questions do not include alcoholic beverages.

Please answer every question. If you have difficulty with a statement, then choose the response that is
mostly right.

In the past zz months... Circle

z. Have you used drugs other than those required for medical reasons? Yes No
2. Do you abuse more than one drug at a time? Yes No
3. Are you unable to stop abusing drugs when you want to? Yes No
S. Have you ever had blackouts or flashbacks as a result of drug use? Yes No
s- Do you ever feel bad or guilty about your drug use? Yes No
6. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No
7. Have you neglected your family because of your use of drugs? Yes No
8. Have you engaged in illegal activities in order to obtain drugs? Yes No
Have you ever experienced withdrawal symptoms (felt sick) when you stopped
9. res No
taking drugs?
Have you had medical problems as a result of your drug use (e.g. memory ION
0 Yes No
* hepatitis, convulsions, bleeding)*
Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which
Score:
a “No” receives 1 point.

Interpretation of Score
Score Degree of Problems Related to Drug Abuse Suggested Action
0 No problems reported None at this time
1-2 Low level Monitor, re-assess at a later date
3-5 Moderate level Further investigation
6-8 Substantial level Intensive assessment
9-10 Severe level Intensive assessment

Drug Abuse Screening Test (DAST-10). (Copyright 1982 by the Addiction Research Foundation.J