[Jefferson County] Brief Addiction Monitor (BAM)

Instructions: 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 ask about the past 30 days.

Please consider each question and answe 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

1. Very Good

2. Good

3. Fair

4. Poor

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

0. None

1. One to three nights

2. Four to eight nights

3. Nine to fifteen nights

4. Sixteen to thirty nights

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

0. None.

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None (Skip to #6)

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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.]

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None (Skip to #8)

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

7. In the past 30 days, how may days did you use any of the following drugs?

7A. Marijuana (cannabis, pot, weed)?

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

7C. Cocaine and/or Crack?

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter- or unknown medications)?

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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

1. Slightly

2. Moderately

3. Considerably

4. Extremely

9. How confident are you that you will NOT use alcohol and drugs in the next 30 days?

0. Not at all

1. Slightly

2. Moderately

3. Considerably

4. Extremely

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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")?

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

12. Does your religion or spirituality help support your recovery?

0. Not at all

1. Slightly

2. Moderately

3. Considerably

4. Extremely

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

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

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?

0. NO

4. YES

15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?

0. Not at all

1. Slightly

2. Moderately

3. Considerably

4. Extremely

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?

0. None

1. One to three days

2. Four to eight days

3. Nine to fifteen days

4. Sixteen to thirty days

17. How satisfied are you with your progress toward achieving your recovery goals?

0. Not at all

1. Slightly

2. Moderately

3. Considerably

4. Extremely

Brief Addiction Monitor (BAM)

Full Name

Method of Administration:

1. In the past 30 days, how would you say your physical health has been?

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 may 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?

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?

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?

9. How confident are you that you will NOT use alcohol and drugs in the next 30 days?

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")?

12. Does your religion or spirituality help support your recovery?

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?

15. In the past 30 days, how much have you been bothered by arguments or problems getting along with any family members or friends?

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?