Download:
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pdfVA Form 10-21087
OMB Number 2900-NEW
Estimated Burden: 45 MIN.
Vietnam-Era Veterans Follow-up
Telephone Survey
The American Legion
The Women Vietnam Veterans Memorial Project
Core Section 3: Health Care Access
Question
Number
Question text
Variable
names
C03.01
Do you have any kind of
health care coverage,
including health
insurance, prepaid plans
such as HMOs, or
government plans such
as Medicare, or Indian
Health Service?
HLTHPLN1
C03.02
Do you have one person
you think of as your
personal doctor or
health care provider?
PERSDOC2
C03.03
Was there a time in the
past 12 months when
you needed to see a
doctor but could not
because of cost?
About how long has it
been since you last
visited a doctor for a
routine checkup?
MEDCOST
C03.04
CHECKUP1
Responses
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
1 Yes
2 No
7 Don’t
know/Not Sure
9 Refused
1 Yes, only one
2 More than one
3 No
7 Don’t know /
Not sure
9 Refused
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
Read if necessary:
1 Within the past
year (anytime
less than 12
months ago)
2 Within the past
2 years (1 year
SKIP INFO/ CATI
Note
Interviewer Note (s)
If using Health Care
Access (HCA) Module
go to Module 03,
M03.01, else
continue
97
If No, read: Is there more than
one, or is there no person who you
think of as your personal doctor or
health care provider?
If using HCA Module,
go to Module 03,
M03.03, else
continue.
If using HCA Module
and C03.01 = 1 go to
Module 03 M03.04
or if using HCA
Module and C03,01 =
2, 7, or 9 go to
Module 03,
Column(s)
98
99
Read if necessary: A routine
checkup is a general physical
exam, not an exam for a specific
injury, illness, or condition.
100
16
18 January 2018
but less than 2
years ago)
3 Within the past
5 years (2 years
but less than 5
years ago)
4 5 or more years
ago
Do not read:
7 Don’t know /
Not sure
8 Never
9 Refused
M03.04A, else go to
next section.
17
18 January 2018
Thinking About Military Service
1. The following statements ask about your attitudes, experiences, and thoughts about your
military service, and how these may have changed compared to when you were younger.
Please read each item carefully and circle the choice that best applies. When responding to
these statements, think about the war(s) in which you served.
Strongly
disagree
Disagree
0
1
0
a) I think about the war more than I used
to.
b) Everyday things have started reminding
me of the war.
c) As I get older, I get more upset when
talking about the war than I used to.
d) My family and friends tell me that I
have recently been speaking more
emotionally about the war.
e) I dream about the war more now than
when I was younger.
f) These days, I become more emotional
around certain days or anniversaries that
remind me of the war.
g) Lately, my thoughts about the war
bother me more.
h) I need to talk about the war more now
than when I was younger.
i) These days, I think more about my role
in the war.
j) When I am faced with stressful events, I
find myself thinking about the war.
k) Lately, I think more about friends I lost
during the war.
Neither
agree
nor
disagree
Agree
Strongly
agree
2
3
4
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
Agent Orange Exposure
2. Were you exposed to Agent Orange?
__Yes
__No
3. If so, how severe was your level of exposure?
_______________________________________
4. Have you experienced any consequences or side effects of exposure?
_______________________________________
5. How often do you find yourself searching to make sense of or find meaning in your
combat experiences?
Never
Sometimes
Often
Very Often
0
1
2
3
6. Experiences can affect our lives in negative and positive ways. To what extent did your
military experience have a negative impact on your life?
Not at all
A little bit
A moderate amount
A great deal
0
1
2
3
7. To what extent did your military experience have a positive impact on your life?
Not at all
A little bit
A moderate amount
A great deal
0
1
2
3
Connor-Davidson Resilience
I have been able to…
1. Adapt to change.
2. Deal with whatever comes my
way.
3. See humorous side of things.
4. Feel that stress makes me
stronger.
5. Bounce back after illness or
injury.
6. Believe that I can achieve goals
despite obstacles.
7. Stay focused under pressure.
8. Not be easily discouraged by
failure.
9. Think of myself as a strong
person when facing challenges.
10. Handle unpleasant feelings.
Not
true
at all
Rarely
true
Someti
mes
true
Often
true
0
0
1
1
2
2
3
3
True
nearly
all
of the
time
4
4
0
0
1
1
2
2
3
3
4
4
0
1
2
3
4
0
1
2
3
4
0
0
1
1
2
2
3
3
4
4
0
1
2
3
4
0
1
2
3
4
Core Section 5: Inadequate Sleep
Question
Number
Question text
Variable
names
C05.01
On average, how many
hours of sleep do you
get in a 24-hour period?
SLEPTIM1
Responses
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
_ _ Number of
hours [01-24]
77 Don’t know /
Not sure
99 Refused
SKIP INFO/ CATI
Note
Interviewer Note (s)
Column(s)
Do not read: Enter hours of sleep in 102-103
whole numbers, rounding 30
minutes (1/2 hour) or more up to
the next whole hour and dropping
29 or fewer minutes.
19
18 January 2018
Core Section 14: Breast and Cervical Cancer Screening
Question
Number
Question text
Variable
names
C14.01
The next questions are
about breast and cervical
cancer. Have you ever
had a mammogram?
HADMAM
How long has it been
since you had your last
mammogram?
HOWLONG
C14.02
Responses
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
1 Yes
2 No
7 Don’t know/
not sure
9 Refused
Read if
necessary:
1 Within the past
year (anytime
less than 12
months ago)
2 Within the past
2 years (1 year
but less than 2
years ago)
3 Within the past
3 years (2 years
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 5 or more years
ago
SKIP INFO/ CATI
Note
Interviewer Note (s)
Column(s)
Skip if male.
A mammogram is an x-ray of each
breast to look for breast cancer.
224
Go to C14.03
225
40
18 January 2018
7 Don’t know /
Not sure
9 Refused
C14.03
C14.04
Have you ever had a Pap
test?
HADPAP2
How long has it been
since you had your last
Pap test?
LASTPAP2
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
Read if
necessary:
1 Within the past
year (anytime
less than 12
months ago)
2 Within the past
2 years (1 year
but less than 2
years ago)
3 Within the past
3 years (2 years
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 5 or more years
ago
7 Don’t know /
Not sure
9 Refused
226
Go to C14.05
227
41
18 January 2018
C14.05
C14.06
C14.07
An H.P.V. test is
HPVTEST
sometimes given with the
Pap test for cervical
cancer screening. Have
you ever had an H.P.V.
test?
How long has it been
HPLSTTST
since you had your last
H.P.V. test?
Have you had a
hysterectomy?
HADHYST2
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
Read if
necessary:
1 Within the past
year (anytime
less than 12
months ago)
2 Within the past
2 years (1 year
but less than 2
years ago)
3 Within the past
3 years (2 years
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 5 or more years
ago
7 Don’t know /
Not sure
9 Refused
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
Go to C14.07
Human papillomarvirus (pap-uhloh-muh virus)
228
229
If response to Core
Q8.20 = 1 (is
pregnant); then go to
next section.
Read if necessary: A hysterectomy
is an operation to remove the
uterus (womb).
230
42
18 January 2018
Core Section 15: Prostate Cancer Screening - for Men Only
Question
Number
Question text
Variable
names
C15.01
Has a doctor, nurse, or
other health professional
ever talked with you
about the advantages of
the Prostate-Specific
Antigen or P.S.A. test?
Has a doctor, nurse, or
other health professional
ever talked with you
about the disadvantages
of the P.S.A. test?
PCPSAAD3
PCPSADI1
1 Yes
2 No
7 Don’t know/
not sure
9 Refused
232
C15.03
Has a doctor, nurse, or
other health professional
ever recommended that
you have a P.S.A. test?
PCPSARE1
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
233
C15.04
Have you ever had a
P.S.A. test?
PSATEST1
1 Yes
234
C15.02
Responses
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
1 Yes
2 No
7 Don’t know/
not sure
9 Refused
2 No
7 Don’t know /
Not sure
9 Refused
SKIP INFO/ CATI Note Interviewer Note (s)
Column(s)
If respondent is ≤39
years of age, or
C08.01 is coded 2,
female, go to next
section.
231
Read if necessary: A prostatespecific antigen test, also called a
P.S.A. test, is a blood test used to
check men for prostate cancer.
Go to next section
43
18 January 2018
C15.05
How long has it been
since you had your last
P.S.A. test?
PSATIME
C15.06
What was the main
PCPSARS1
reason you had this P.S.A.
test – was it …?
Read if
necessary:
1 Within the past
year (anytime
less than 12
months ago)
2 Within the past
2 years (1 year
but less than 2
years ago)
3 Within the past
3 years (2 years
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 5 or more years
ago
Do not read:
7 Don’t know /
Not sure
9 Refused
Read:
1 Part of a
routine exam
2 Because of a
prostate problem
3 Because of a
family history of
prostate cancer
4 Because you
were told you
had prostate
cancer
235
236
44
18 January 2018
5 Some other
reason
Do not read:
7 Don’t know /
Not sure
9 Refused
45
18 January 2018
Core Section 16: Colorectal Cancer Screening
Question
Number
Question text
Variable
names
C16.01
A blood stool test is a test
that may use a special kit
at home to determine
whether the stool
contains blood. Have you
ever had this test using a
home kit?
How long has it been
since you had your last
blood stool test using a
home kit?
BLDSTOOL
C16.02
Responses
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
LSTBLDS3
Read if necessary:
1 Within the past
year (anytime less
than 12 months
ago)
2 Within the past
2 years (1 year but
less than 2 years
ago)
3 Within the past
3 years (2 years
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 5 or more years
ago
Do not read:
7 Don’t know /
Not sure
9 Refused
SKIP INFO/ CATI
Note
Skip if Section 08.02,
AGE, is less than 50
Go to C16.03
Interviewer Note (s)
Column(s)
237
238
46
18 January 2018
C16.03
C16.04
C16.05
Sigmoidoscopy and
colonoscopy are exams in
which a tube is inserted
in the rectum to view the
colon for signs of cancer
or other health problems.
Have you ever had either
of these exams?
For a sigmoidoscopy, a
flexible tube is inserted
into the rectum to look
for problems. A
colonoscopy is similar,
but uses a longer tube,
and you are usually given
medication through a
needle in your arm to
make you sleepy and told
to have someone else
drive you home after the
test. Was your most
recent exam a
sigmoidoscopy or a
colonoscopy?
How long has it been
since you had your last
sigmoidoscopy or
colonoscopy?
HADSIGM3
1 Yes
2 No
7 Don’t know /
Not sure
9 Refused
239
Go to next section
HADSGCO1
1 Sigmoidoscopy
2 Colonoscopy
7 Don’t know /
Not sure
9 Refused
240
LASTSIG3
Read if necessary:
1 Within the past
year (anytime less
than 12 months
ago)
2 Within the past
2 years (1 year but
less than 2 years
ago)
3 Within the past
3 years (2 years
241
47
18 January 2018
but less than 3
years ago)
4 Within the past
5 years (3 years
but less than 5
years ago)
5 Within the past
10 years (5 years
but less than 10
years ago)
6 10 or more
years ago
Do not read:
7 Don't know /
Not sure
9 Refused
48
18 January 2018
Module 13: Lung Cancer Screening
Question
Number
Question text
M13.01
You’ve told us that you
have smoked in the past
or are currently smoking.
The next questions are
about screening for lung
cancer.
Variable
names
Responses
LCSFIRST
_ _ _ Age in Years
(001 – 100)
777 Don't
know/Not sure
999 Refused
How old were you when
you first started to smoke
cigarettes regularly?
How old were you when
you last smoked
cigarettes regularly?
LCSLAST
M13.03
On average, when you
{smoke/smoked}
regularly, about how
many cigarettes {do/did}
you usually smoke each
day?
LCSNUMCG
Column(s)
If C09.01=1 (yes) and
C09.02 = 1, 2, or 3
(every day, some
days, or not at all)
continue, else go to
question M13.04.
354-356
(DO NOT READ
UNLESS
OTHERWISE
NOTED)
888 Never
smoked
cigarettes
regularly
M13.02
SKIP INFO/ CATI Note Interviewer Note (s)
_ _ _ Age in Years
(001 – 100)
777 Don't
know/Not sure
999 Refused
_ _ _ Number
of cigarettes
777 Don't
know/Not sure
999 Refused
Go to M13.04
Regularly is at least one cigarette
or more on days that a respondent
smokes (either every day or some
days) or smoked (not at all).
If respondent indicates age
inconsistent with previously
entered age, verify that this is the
correct answer and change the
age of the respondent regularly
smoking or make a note to correct
the age of the respondent.
357-359
Regularly is at least one cigarette
or more on days that a respondent
smokes (either every day or some
days) or smoked (not at all).
Respondents may answer in packs
instead of number of cigarettes.
Below is a conversion table: 0.5
pack = 10 cigarettes/ 1.75 pack =
360-362
82
18 January 2018
35 cigarettes/ 0.75 pack = 15
cigarettes/ 2 packs = 40 cigarettes/
1 pack = 20 cigarettes/ 2.5 packs=
50 cigarettes/ 1.25 pack = 25
cigarettes/ 3 packs= 60 cigarettes/
1.5 pack = 30 cigarettes
M13.04
The next question is
about CT or CAT scans.
During this test, you lie
flat on your back on a
table. While you hold
your breath, the table
moves through a donut
shaped x-ray machine
while the scan is done. In
the last 12 months, did
you have a CT or CAT
scan?
LCSCTSCN
Read if
necessary:
1 Yes, to check
for lung cancer
2 No (did not
have a CT scan)
3 Had a CT scan,
but for some
other reason
Do not read:
7 Don't know/not
sure
9 Refused
363
83
18 January 2018
Module 14: Cancer Survivorship
Question
Number
Question text
M14.01
You’ve told us that you
have had cancer. I
would like to ask you a
few more questions
about your cancer.
Variable names Responses
(DO NOT READ
UNLESS OTHERWISE
NOTED)
CNCRDIFF
How many different
types of cancer have
you had?
M14.02
At what age were you
told that you had
cancer?
CNCRAGE
M14.03
What type of cancer
was it?
CNCRTYP1
SKIP INFO/ CATI
Note
1 Only one
2 Two
3 Three or more
If C06.06 or C06.07
= 1 (Yes) or C15.06 =
4 (Because you
were told you had
prostate cancer)
continue, else go to
next module.
7 Don’t know / Not
sure
9 Refused
_ _ Age in Years (97 =
97 and older)
98 Don't know/Not
sure
99 Refused
Go to next module
Read if respondent
needs prompting for
cancer type:
01 Breast cancer
Female reproductive
(Gynecologic)
02 Cervical cancer
(cancer of the cervix)
If C06.06 = 1 (Yes)
and M14.01 = 1
(Only one): ask Was
it Melanoma or
other skin cancer?
then code 21 if
Melanoma or 22 if
other skin cancer
Interviewer Note (s)
Column(s)
364
If M14.01= 2 (Two) or 3 (Three or
more), ask: At what age were
you first diagnosed with cancer?
Read if necessary: This question
refers to the first time they were
told about their first cancer.
If M14.01 = 2 (Two) or 3 (Three
or more), ask: With your most
recent diagnoses of cancer, what
type of cancer was it?
365-366
367-368
84
18 January 2018
03 Endometrial
cancer (cancer of the
uterus)
04 Ovarian cancer
(cancer of the ovary)
Head/Neck
05 Head and neck
cancer
06 Oral cancer
07 Pharyngeal
(throat) cancer
08 Thyroid
09 Larynx
Gastrointestinal
10 Colon (intestine)
cancer
11 Esophageal
(esophagus)
12 Liver cancer
13 Pancreatic
(pancreas) cancer
14 Rectal (rectum)
cancer
15 Stomach
Leukemia/Lymphoma
(lymph nodes and
bone marrow)
16 Hodgkin's
Lymphoma (Hodgkin’s
disease)
17 Leukemia (blood)
cancer
18 Non-Hodgkin’s
Lymphoma
Male reproductive
19 Prostate cancer
CATI note: If C16.06
= 4 (Because you
were told you had
Prostate Cancer)
and Q1 = 1 (Only
one) then code 19.
85
18 January 2018
M14.04
Are you currently
receiving treatment for
cancer?
CSRVTRT2
20 Testicular cancer
Skin
21 Melanoma
22 Other skin cancer
Thoracic
23 Heart
24 Lung
Urinary cancer
25 Bladder cancer
26 Renal (kidney)
cancer
Others
27 Bone
28 Brain
29 Neuroblastoma
30 Other
Do not read:
77 Don’t know / Not
sure
99 Refused
Read if necessary:
1 Yes
2 No, I’ve completed
treatment
3 No, I’ve refused
treatment
4 No, I haven’t
started treatment
7 Don’t know / Not
sure
9 Refused
Go to next module
Read if necessary: By treatment,
we mean surgery, radiation
therapy, chemotherapy, or
chemotherapy pills.
369
Go to next module
86
18 January 2018
M14.05
M14.06
M14.07
What type of doctor
provides the majority
of your health care? Is
it a….
Did any doctor, nurse,
or other health
professional ever give
you a written summary
of all the cancer
treatments that you
received?
Have you ever received
instructions from a
doctor, nurse, or other
health professional
about where you
should return or who
you should see for
routine cancer checkups after completing
CSRVDOC1
CSRVSUM
CSRVRTRN
Read:
01 Cancer Surgeon
02 Family Practitioner
03 General Surgeon
04 Gynecologic
Oncologist
05 General
Practitioner, Internist
06 Plastic Surgeon,
Reconstructive
Surgeon
07 Medical Oncologist
08 Radiation
Oncologist
09 Urologist
10 Other
Do not read:
77 Don’t know / Not
sure
99 Refused
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
If the respondent requests
clarification of this question, say:
We want to know which type of
doctor you see most often for
illness or regular health care
(Examples: annual exams and/or
physicals, treatment of colds,
etc.).
Read if necessary: An oncologist
is a medical doctor who manages
a person’s care and treatment
after a cancer diagnosis.
Read if necessary: By ‘other
healthcare professional’, we
mean a nurse practitioner, a
physician’s assistant, social
worker, or some other licensed
professional.
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
370-371
372
373
Go to M14.09
87
18 January 2018
your treatment for
cancer?
M14.08
Were these
instructions written
down or printed on
paper for you?
CSRVINST
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
M14.09
With your most recent
diagnosis of cancer, did
you have health
insurance that paid for
all or part of your
cancer treatment?
Were you ever denied
health insurance or life
insurance coverage
because of your
cancer?
CSRVINSR
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
CSRVDEIN
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
376
M14.11
Did you participate in a
clinical trial as part of
your cancer treatment?
CSRVCLIN
377
M14.12
Do you currently have
physical pain caused by
your cancer or cancer
treatment?
CSRVPAIN
Would you say your
pain is currently under
control…?
CSRVCTL1
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
1 Yes
2 No
7 Don’t know/ not
sure
9 Refused
Read:
1 With medication (or
treatment)
M14.10
M14.13
374
Read if necessary: Health
insurance also includes
Medicare, Medicaid, or other
types of state health programs.
375
378
Go to next module
379
88
18 January 2018
2 Without medication
(or treatment)
3 Not under control,
with medication (or
treatment)
4 Not under control,
without medication
(or treatment)
Do not read:
7 Don’t know / Not
sure
9 Refused
89
18 January 2018
A. WHO - ASSIST V3.0
INTERVIEWER ID
COUNTRY
PATIENT ID
CLINIC
DATE
INTRODUCTION (Please read to patient )
Thank you for agreeing to take part in this brief interview about alcohol, tobacco products and other
drugs. I am going to ask you some questions about your experience of using these substances across
your lifetime and in the past three months. These substances can be smoked, swallowed, snorted,
inhaled, injected or taken in the form of pills (show drug card).
Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain
medications). For this interview, we will not record medications that are used as prescribed by your
doctor. However, if you have taken such medications for reasons other than prescription, or taken them
more frequently or at higher doses than prescribed, please let me know. While we are also interested in
knowing about your use of various illicit drugs, please be assured that information on such use will be
treated as strictly confidential.
NOTE: BEFORE ASKING QUESTIONS
QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT
Question 1
(if completing followfollow-up please cross check the patient’s answers with the answers given for Q1 at
baseline. Any differences on this question should be queried)
In your life, which of the following substances have you
No
Yes
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
3
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
3
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
3
d. Cocaine (coke, crack, etc.)
0
3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
3
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
3
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
3
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
3
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
3
j. Other - specify:
0
3
ever used?
USE
SE ONLY)
used? (NON(NON-MEDICAL U
Probe if all answers are negative:
“Not even when you were in school?”
If "No" to all items, stop interview.
If "Yes" to any of these items, ask Question 2 for
each subst
substance
ance ever used.
Question 2
Once or
Twice
Monthly
Weekly
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
2
3
4
6
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
2
3
4
6
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
2
3
4
6
d. Cocaine (coke, crack, etc.)
0
2
3
4
6
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
2
3
4
6
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
2
3
4
6
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
2
3
4
6
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
2
3
4
6
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
2
3
4
6
j. Other - specify:
0
2
3
4
6
the substances you mentioned (FIRST DRUG,
SECOND DRUG, ETC)?
ETC)?
Daily or
Almost
Daily
Never
In the past three months,
months, how often have you used
If "Never" to all items in Question 2, skip to Question 6.
If any substances in Question 2 were used in the previous three months, continue with
Questions 3, 4 & 5 for each substance
substance used.
Question 3
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost
Daily
During the past three months,
months, how often have you
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
3
4
5
6
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
3
4
5
6
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
3
4
5
6
d. Cocaine (coke, crack, etc.)
0
3
4
5
6
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
3
4
5
6
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
3
4
5
6
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
3
4
5
6
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
3
4
5
6
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
3
4
5
6
j. Other - specify:
0
3
4
5
6
had a strong desire or urge to use (FIRST DRUG, SECOND
DRUG, ETC)?
ETC)?
Question 4
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost
Daily
During the past three months,
months, how often has your
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
4
5
6
7
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
4
5
6
7
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
4
5
6
7
d. Cocaine (coke, crack, etc.)
0
4
5
6
7
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
4
5
6
7
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
4
5
6
7
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
4
5
6
7
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
4
5
6
7
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
4
5
6
7
j. Other - specify:
0
4
5
6
7
use of (FIRST DRUG, SECOND DRUG, ETC)
ETC)
led to health, social, legal or financial problems?
Question 5
Never
Once or
Twice
Monthly
Weekly
Daily or
Almost
Daily
During the past three months,
months, how often have you failed
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
5
6
7
8
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
5
6
7
8
d. Cocaine (coke, crack, etc.)
0
5
6
7
8
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
5
6
7
8
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
5
6
7
8
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
5
6
7
8
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
5
6
7
8
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
5
6
7
8
j. Other - specify:
0
5
6
7
8
to do what was normally expected of you because of
your use of (FIRST DRUG, SECOND DRUG, ETC)?
ETC)?
a. Tobacco products
Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1)
Yes, in the
past 3
months
Yes, but
not in the
past 3
months
No, Never
Question 6
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
6
3
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
6
3
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
6
3
d. Cocaine (coke, crack, etc.)
0
6
3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
6
3
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
6
3
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
6
3
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
6
3
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
6
3
j. Other – specify:
0
6
3
Has a friend or relative or anyone else ever
expressed concern about your use of
(FIRST DRUG, SECOND DRUG, ETC.)?
Yes, in the
past 3
months
Yes, but
not in the
past 3
months
No, Never
Question 7
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
0
6
3
b. Alcoholic beverages (beer, wine, spirits, etc.)
0
6
3
c. Cannabis (marijuana, pot, grass, hash, etc.)
0
6
3
d. Cocaine (coke, crack, etc.)
0
6
3
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
0
6
3
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
0
6
3
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
0
6
3
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
0
6
3
i. Opioids (heroin, morphine, methadone, codeine, etc.)
0
6
3
j. Other – specify:
0
6
3
Have you ever tried and failed to control, cut down or stop using
(FIRST DRUG, SECOND DRUG, ETC.)?
0
(NON(NON-MEDICAL USE ONLY)
Yes, but
not in the
past 3
months
Have you ever used any drug by injection?
Yes, in the
past 3
months
No, Never
Question 8
2
1
IMPORTANT NOTE:
Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting
during this period, to determine their risk levels and the best course of intervention.
PATTERN OF INJECTING
INTERVENTION GUIDELINES
Once weekly or less
less
or
Brief Intervention including “risks
associated with injecting” card
or
Further assessment and more intensive
treatment*
Fewer than 3 days in a row
More than once per week
3 or more days in a row
HOW TO CALCULATE A SSPECIFIC
PECIFIC SUBSTANCE IN
INVOLVEMENT
VOLVEMENT SCORE.
For each substance (labelled a. to j.) add up the scores received for questions 2 through 7 inclusive. Do
not include the results from either Q1 or Q8 in this score. For example, a score for cannabis would be
calculated as: Q2c + Q3c + Q4c + Q5c + Q6c + Q7c
Note that Q5 for tobacco is not coded, and is calculated as: Q2a + Q3a + Q4a + Q6a + Q7a
THE TYPE OF INTERVENT
INTERVENTION
ION IS DETERMINED BY THE PATIENT’S SPECIFIC SUBSTANCE INVOLVEMENT SCORE
Record specific
no intervention
substance score
score
receive brief
more intensive
intervention
treatment *
a. tobacco
0-3
4 - 26
27+
b. alcohol
0 - 10
11 - 26
27+
c. cannabis
0-3
4 - 26
27+
d. cocaine
0-3
4 - 26
27+
e. amphetamine
0-3
4 - 26
27+
f. inhalants
0-3
4 - 26
27+
g. sedatives
0-3
4 - 26
27+
h. hallucinogens
0-3
4 - 26
27+
i. opioids
0-3
4 - 26
27+
j. other drugs
0-3
4 - 26
27+
NOTE: *FURTHER
AND
D MORE INTENSIVE TREATMENT
ASSESSMENT AN
TREATMENT
may be provided by the health professional(s)
within your p
primary
rimary care setting, or, by a specialist drug and alcohol treatment service when available.
B. WHO ASSIST V3.0 RESPONSE CARD FOR PATIENTS
Response Card - substances
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other - specify:
Response Card (ASSIST Questions 2 – 5)
Never: not used in the last 3 months
Once or twice: 1 to 2 times in the last 3 months.
Monthly: 1 to 3 times in one month.
Weekly: 1 to 4 times per week.
Daily or almost daily: 5 to 7 days per week.
Response Card (ASSIST Questions 6 to 8)
No, Never
Yes, but not in the past 3 months
Yes, in the past 3 months
| File Type | application/pdf |
| File Modified | 2018-06-06 |
| File Created | 2018-05-17 |