ASI-X INTERVIEW FORM INSTRUCTIONS. Leave no blanks When appropriate code items: X=Question not answered N=Question not applicable Use only one character per item. Questions in bold italics are critical items.. Space is provided after sections for additional comments S The ratings are estimations of the patient's need for additional treatment in each area. The scale ranges from 0 (no treatment necessary) through 9 (treatment needed to intervene in lifethreatening situation). Each rating is based upon the patient's history of problem symptoms, present conditions and subjective assessment of treatment needs in a given area. rent problems and the perception of treatment needs within each area. For a detailed description of severity ratings derivation procedures and conventions, please consult the manual ASI-X v., 999-0-08, Öberg, D., Zingmark, D. & Sallmén, B. ASI-X is based on the Expanded Female Version of the Addiction Severity Index (ASI) instrument, The ASI-F (Brown, E., Frank, D. & Friedman, A. 997). ASI-X is adapted to comparability with the EuropASI (Blanken et al. 99). ASI-X has been developed with support from the Swedish council for crime prevention (BRÅ), the Department for Clinical Neuroscience at Karolinska Hospital, The Swedish Prison and Probation Administration (KVS) and the National Board of Institutional care (SiS). PATIENT S RATING SCALE 0=Not at all =Slightly =Moderately =Considerably =Extremely PATIENT RATING AND SEVERITY PROFILES 0 0 Patient rating problem Medical Emlpoy./sup. Alcohol Drug Legal Family/social Psycholog. Patient rating help 9 8 7 6 5 0 Severity profile Medical Emlpoy./sup. Alcohol Drug Legal Family/social Psycholog. Name: AJ. Interviewer code number: AA. I.D. number: AB. Type of treatment service: 0=No treatment 7=Psychiatric hospital =Outpatient detoxification 8=Other hospital/ward =Detoxification residential 9=Other =Outpatient substitution 0=Jail/Prison =Outpatient drug-free =Probation 5=Drug-free residential =Custody 6=Day care AK. Special: =Patient terminated =Patient refused =Patient unable to respond AL. Date from which last 0 days are counted: Y Y Y Y M M D D AM. Country code AC. AD. Date of admission: Date of interview: Y Y Y Y M M D D Y Y Y Y M M D D AN. AO. Unit code COMMENTS: AE. Time begun: (HH MM) AF. Time ended: (HH MM) AG. Class: =Intake =Follow/up ( No of assessment) AH. AI. Contact code: =In person =Phone Gender: =Male =Female
B. GENERAL INFORMATION B. Current residence: =Large city (>00.000) =Medium (0.000-00.000) =Small (rural) (<0.000) B. City code: B. How long have you lived at this address? Y Y M M B. Is this residence owned by you or your family? Ba. Have you been homeless during the last 0 days? Bb. If yes, where did you stay during these days? =Shelter =In a building =Friends 5=Outside =Car/caravan 6=Other B5. Age: B6. Nationality: B7. Country of birth of: a Respondent b Father c Mother B8 Have you been in a controlled environment in the past 0 days? =No 5=Psychiatric treatment =Jail 6=Detoxification only =Alcohol or drug treatment 7=Other =Medical treatment B9 If -7 on B8, how many days? B0. How many times have you been/made someone pregnant? B. How many times has a pregnancy resulted in childbirth? Bb. How many different persons have you had these children with? B. How old were you when the first baby was born? Ba. Enter birth dates for your children in column Starting with the oldest child (YYYYMMDD) Bb. Note the children's sex in column =Boy =Girl N=Question not applicable Bc. Note where the children presently are living in column =With mother and father 5=Adopted =Mothers care 6=Institution (type) =Fathers care 7=Died (when) =Care of family member 8=Other 5=Foster care Date of birth Sex Living Ba. Are there other children living with you now that you take care of? 0 =No =Yes Bb. If yes on Ba, note sex: =Male =Female Bc. If yes on Ba, note age: a Sex b Age 5 B5. COMMENTS: 5 6 7 8 9
C MEDICAL STATUS C. How many times in your life have you been hospitalized for medical problems? (include o.d. s, d.t. s, exclude detoxification) C. How long ago was your last hospitalization for medical problems? Y Y C. Do you have any chronic medical problems which continue to interfere with your life? Ca. If Yes, specify: C. Have you ever had any of the following health problems? 0=No =Don't know =Yes =Refuses to answer a Hepatitis B b Hepatitis C c Venereal diseases (excluding HIV) d Tuberculosis e Pelvic Inflammatory Disease f Fits or seizures M M C5. Have you been tested for HIV? 0=No =Don't know =Yes =Refuses to answer C6. If yes on C5, how many months ago? C7. If yes on C5, what was the last test result? 0=HIV-negative =Don't know =HIV-positive =Refuses to answer C7b. If HIV-positive (C7, alternative ), have you developed AIDS? 0=No =Don't know =Yes =Refuses to answer C8. Are you taking any prescribed medication on a regular basis for a physical problem? C9. Do you receive a pension for a medical disability? (exclude psychiatric disability) C0. Have you been treated for medical problems by a physician during the past 6 months? C. How many days have you experienced medical problems in the past 0 days? FOR QUESTIONS C & C PLEASE ASK PATIENT TO USE THE PATIENT S RATING SCALE C7. COMMENTS: C. How troubled or bothered have you been by these medical problems in the past 0 days? C. How important to you now is treatment for these medical problems? C. How would you rate the patient s need for medical treatment? C5. Patient s misrepresentation? C6. Patient s inability to understand?
D EMPLOYMENT/SUPPORT STATUS D. Years of school education: (Years) D. Years of higher education: (University/technical) D. Highest degree of education obtained: a (specify) D. Do you have a valid driver s license? D5. How long was your longest period of regular employment? Y Y M M (see manual for definition) D6. How long was your longest period of unemployment Y Y M M D7. Usual (or last) occupation? a (specify in detail) D7b. Does any person contribute to your support? D7c. If yes on 7b, who is this person? =Spouse/partner 5=Child =Earlier spouse/partner 6=Grandparents =Parents/foster parents 7=Other relative =Sibling 8=Other D7d If yes on 7b, is this person your main source of support D8. Usual employment pattern in the past years? =Full time 5=Military services =Part-time (reg. hrs) 6=Retired/disability =Part-time (irregular, day work) 7=Unemployed (incl. housewife) =Student 8=In controlled environment D9. How many days have you been working during the past 0 days? (exclude dealing/prostitution or other illegal) D9b. How many days have you been sick-listed during the past 0 days? D0 How much money did you receive from employment in the past 0 days? (after tax) Did you receive money for your support from the following sources during the past 0 days? D. Unemployment compensation? D. Public assistance or welfare? D. Pension, benefits, or social security? D. Mate, family or friends? (money for personal expenses) D5. Illegal? D6. Prostitution? D7. Other sources? D8. Which is the major source of your support? (use code 0-7) D9. Do you have any debts? D9a. If yes on D9, amount D0. How many people depend on you for the majority of their food, shelter, etc? D. How important to you now is counselling for these employment problems? D. How would you rate the patient s need for employment counselling? D5. Patient s misrepresentation? D6. Patient s inability to understand? D7. COMMENTS: D. How many days have you experienced employment/unemployment problems in the past 0? FOR QUESTIONS D & D PLEASE ASK PATIENT TO USE THE PATIENT S RATING SCALE D. How troubled or bothered have you been by these employment problems in the past 0 days?
E DRUG/ALCOHOL USE E. Alcohol any use E. Alcohol over threshold E. Heroin E. Methadone/LAAM E5. Other opiates/analgesics E6. Medicine/pills (see manual) E7. Cocaine E8. Amphetamines E9. Cannabis E0. Hallucinogens E. Inhalants E. Other Age Lifetime Past 0 Rt of first use Yrs. days adm* E. Have you ever injected? Ea. (if yes on E, concerns any injections) a Age st injection. (YY) b Lifetime. (number of years) c Injection past 6 months. (number of months) d Last 0 days. (number of days) b. If injections past 6 months: =Not sharing =Often sharing with other =Sometimes sharing with other E5. How many times had you: a Had alcohol d.t s: b Overdosed on drugs: E5c. Do you smoke cigarettes? E5d. If yes, about how many cigarettes did you smoke during the past 0 days? E. More than one substance per day (items to ) Note: See manual for representative examples for each drug class *Route of administration: =Oral =Nasal =Smoking =Non IV inj. 5=IV inj. 6=Other E5e. How many times during the past 0 days did you stay up past a.m. because you were using drugs or alcohol? 0=None =Once =Twice =Three times =Four or more times E5f. Do you sleep until after a.m. most days?, not related to working hours =Yes, related to working hours E6. Type of services and times received treatment: Alcohol Drugs Outpatient detoxification Detoxification residential Outpatient substitution Outpatient drug-free 5 Drug-free residential 6 Day care 7 Psychiatric hospital 8 Other hospital/ward 9 Other treatment E7. How many months lasted the longest period that you have been abstinent/clean as the result of these treatments? a Alcohol b Drugs E8. Which substance is the major problem? Please code as above (-) or, see below. When not clear, ask patient. 00=No problem 5=Alcohol & Drug (dual addiction) 6=Polydrug E9. How long was your last period of (months) voluntary abstinence from this major substance not as consequence of treatment? (00=never abstinent) E0. How many months ago did this abstinence end? (00=still abstinent) E. How much would you say you spent during the past days on: a Alcohol (amount ) b Drugs (amount ) E. How many days of the past 0 have you received outpatient treatment? (include AA, NA, etc.) E. How many days in the past 0 have you experienced: a Alcohol problems b Drug problems 5
FOR QUESTIONS E & E5 PLEASE ASK PATIENT TO USE THE PATIENT S RATING SCALE E. How troubled or bothered have you been in the past 0 days by these: a Alcohol problems b Drug problems E5. How important to you now is treatment for these: E7. Patient s misrepresentation? E8. Patient s inability to understand? E9. COMMENTS: a Alcohol problems b Drug problems E6. How would you rate the patient s need for treatment for: a Alcohol problems b Drug problems F LEGAL STATUS F. Was this admission prompted or suggested by the criminal justice system? (judge, probation/parole officer, etc.) F. Are you on probation or parole? How many times in your life have you been charged for the following: (if never, code 0) F. Possession and dealing of drugs? F. Crimes against property? (burglary, larceny, shoplifting, fraud, forgery, extortion, receiving) F5. Crimes of violence? (robbery, assault, arson, rape, homicide, manslaughter) F6. Other crimes? F7. How many of these charges (F-F6) resulted in convictions? How many times in your life have you been charged with the following: (if never, code 0) F8. Disorderly conduct, vagrancy, public intoxication? F9. Prostitution? F0. Driving while intoxicated? F. Major driving violations? (reckless driving, speeding, no license, etc.) F. How many months were you Mos. incarcerated in your life? (If never, code 0) F. If yes on F, how long was Mos. your last incarceration? F. If yes on F, What was it for? (Use code 0-06, 08-. If multiple charges, code most severe) F5. Are you presently awaiting charges, trial or sentence? F6. If yes on F5, what for? (if multiple charges, code most severe) F7. How many days in the past 0 were you detained or incarcerated? F8. How many days in the past 0 have you engaged in illegal activities for profit? (if never, code 0) 6
FOR QUESTIONS F9 & F0 PLEASE ASK PATIENT TO USE THE PATIENT'S RATING SCALE F COMMENTS: F9. How serious do you feel your present legal problems are? (exclude civil problems) F0. How important to you now is counselling or referral for these legal problems? F. How would you rate the patient s need for legal services or counselling? F. Patient s misrepresentation? F. Patient s inability to understand? G FAMILY HISTORY: ADDICTION, CRIMINALITY AND PSYCHIATRIC PROBLEMS Have any of your relatives had what you would call a significant drinking, drug use, psychiatric or criminal problem one that did or should led to treatment? a Mother s side b Father s side c Siblings d Children -Alc -Drug -Psy -Crim -A -D -P -C -A -D -P -C -A -D -P -C Gr.mother Gr.mother Brother Child Gr.father Gr.father Brother Child Mother Father Sister Child Aunt Aunt Sister Child 5 Uncle 5 Uncle 5 Step sibl. 5 Child 5 6 Imp.others 6 Imp.others 6 Child 6 DIRECTIONS: Code most problematic sibling in cases of more than two per category. 0=Clearly no for all relatives in the category =Clearly yes for any relative within the category X=Uncertain or I don t know N=There never was a relative from that category G7. COMMENTS: COLUMNS: =A=Alcohol problems =D=Drug problems =P=Psychiatric problems =C=Criminal problems 7
H FAMILY/SOCIAL RELATIONSHIPS H. Martial status: =Married =Remarried =Widowed =Separated 5=Divorced 6=Never married: H. How long have you been in this martial status? (if never married, since 8) Y Y H. Are you satisfied with this situation? 0=No =Indifferent =Yes H. Usual living arrangements? (past years) =With sexual partner and children 6=With friends =With sexual partner alone 7=Alone =With children alone 8=Controlled environment =With parents 9=No stable arrangements 5=With family M M H5. How long have you lived in these arrangements? Y Y M M (if with parents or family since age 8) H6. Are you satisfied with these living arrangements? 0=No =Indifferent =Yes Do you live with anyone who: H6a. Has a current alcohol problem? H6b. Uses psychoactive drugs? H7. With whom do you spend most of your free time? =Family, without current alcohol or drug problems =Family, with current alcohol or drug problems =Friends, without current alcohol or drug problems =Friends, with current alcohol or drug problems 5=Alone H8. Are you satisfied with spending your free time this way? 0=No =Indifferent =Yes H9. How many close friends do you have? DIRECTION FOR H9a + H0-H 8: 0=Clearly no for all in the category =Clearly yes for any within the category X=Uncertain or I don t know N=There never was a relative from that category H9a. Would you say you have had close, long lasting, personal relationships, with any of the following people in your life? Mother Father Sibling Sexual partner/spouse 5 Children 6 Friends H9b. How much do you feel cared about, liked or loved by the significant people i your life? (such as family members, friends, and so on) 0=Not at all =Somewhat =A little =A lot H9c. To what degree do you feel you need more emotional support? 0=Not at all =Somewhat =A little =A lot Have you had significant periods in which you have experienced serious problems getting along with: Past In 0 days your life H0. Mother H. Father H. Siblings H. Sexual partner/spouse H. Children H5. Other close relative Did any of these people (H0-H8) or any others (stranger/acquaintances) abuse you: Past In 0 days your life H8a. Emotionally? (make you feel bad through harsh words) H8b. Physically? (cause you physical harm) H8c. Sexually? (rape, forced sexual advances or non-consensual sexual acts) H8d. Sexual harassment? (inappropriate physical contact, stalking, using threats to secure sexual contact, etc.) H9. How many days of the past 0 have you had serious conflicts: a With your family? (days) b With other people? (days) (excluding family) H6. Close friends H7. Neighbors H8. Co-workers 8
FOR QUESTIONS H0 - H PLEASE ASK PATIENT TO USE THE CLIENT S RATING SCALE How troubled or bothered have you been in the past 0 days by these: H6. Patient s inability to understand? COMMENTS: H0. Family problems? H. Social problems? How important now is treatment or counselling for these: H. Family problems? H. Social problems? H. How would you rate the patient s need for family and/or social counselling? H5. Patient s misrepresentation? i PSYCHIATRIC STATUS i. How many times have you been treated for any psychological or emotional problems: a As inpatient? b As outpatient? i. Do you receive a pension for a psychiatric disability? Have you had a significant period, in which you have: (Questions i-i6+i8 concerns period that was Past In not a direct result of drug or alcohol use) 0 days your life (see manual for definitions) i. Experienced serious depression? i. Experienced serious anxiety or tension? i5. Experienced trouble understanding, concentrating, or remembering? i6. Experienced hallucinations? i7. Experienced trouble controlling violent behaviour? i8. Been prescribed medication for any psychological/emotional problem? i9. Experienced serious thoughts of suicide? i0. Attempted suicide? i0a. How many times have you attempted suicide? i0b. Experienced anorexia, bulimia or other eating disorders? Past In 0 days your life In the past 0, to what degree were you bothered by past experiences involving: 0=Not at all =Somewhat =A little =A lot i0c. Emotional abuse? i0d. Physical abuse? i0e. Sexual abuse? (excluding rape and harassment) i0f. Rape? i0g. Sexual harassment? 9
i. How many days of the past 0 have you experienced these psychological/ emotional problems? FOR QUESTIONS i & i PLEASE ASK PATIENT TO USE THE PATIENT S RATING SCALE i. How much have you been troubled or bothered by these psychological or emotional problems in the past 0 days? i. How important to you now is treatment for these psychological problems? THE FOLLOWING ITEMS ARE TO BE COMPLETED BY THE INTERVIEWER At the time of the interview, is patient: i. Obviously depressed/withdrawn? i5. Obviously hostile? i6. Obviously anxious/nervous? At the time of the interview, is patient: i7. Having trouble with reality testing, thought disorders, paranoid thinking? i8. Having trouble comprehending, concentrating, remembering? i9. Having suicidal thoughts? i0. How would you rate the patient s need for psychiatric/psychological treatment? i. Patient s misrepresentation? i. Patient s inability to understand? i. COMMENTS: INTERVIEW COMPLETED: H H M M 0