BRIEF ADDICTION MONITOR-REVISED (BAM-R) PAGE

Name(Required)

First Last

Date(Required)

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 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?(Required)

Excellent (0)

Very Good (8)

Good (15)

Fair (22)

Poor (30)

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

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

4. In the past 30 days, how many days did you drink ANY alcohol? (If 0, Skip to #6)(Required)

Please enter a number from 0 to 30.

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.](Required)

Please enter a number from 0 to 30.

6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications? (If 0, Skip to #8)(Required)

Please enter a number from 0 to 30.

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

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

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

7C. Cocaine and/or Crack?(Required)

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

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

Please enter a number from 0 to 30.

8. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?(Required)

Not at all (0)

Slightly (8)

Moderately (15)

Considerably (22)

Extremely (30)

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

Not at all (0)

Slightly (8)

Moderately (15)

Considerably (22)

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?(Required)

Please enter a number from 0 to 30.

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”)?(Required)

Please enter a number from 0 to 30.

12. Does your religion or spirituality help support your recovery?(Required)

Not at all (0)

Slightly (8)

Moderately (15)

Considerably (22)

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?(Required)

Please enter a number from 0 to 30.

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?(Required)

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?(Required)

Not at all (0)

Slightly (8)

Moderately (15)

Considerably (22)

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?(Required)

Please enter a number from 0 to 30.

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

Not at all (0)

Slightly (8)

Moderately (15)

Considerably (22)

Extremely (30)

Brief Addiction Monitor-Revised (BAM-R) Form