Alcohol - Complete Case 1
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: burning foot pain, diagnosed with Diabetes
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? Last night
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? I don’t use drugs
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you drink? About 1 pint of vodka
How frequently do you drink? You drink about 1 pint almost every night
Patient Answers to AUDIT:
1. How often do you have a drink containing alcohol?
4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
Maybe 8 or so
3. How often do you have six or more drinks on one occasion?
Pretty much everyday
4. During the past year, how often have you found that you were not able to stop drinking once you had started?
Sometimes on the weekends, like once every couple of months
5. During the past year, how often have you failed to do what was normally expected of you because of drinking?
Less than monthly
6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
Less than monthly
7. During the past year, how often have you had a feeling of guilt or remorse after drinking?
Less than monthly
8. During the past year, have you been unable to remember what happened the night before because you had
been drinking?
It happens, not a whole lot but it happens I guess like once every couple of months
9. Have you or someone else been injured as a result of your drinking?
Yeah but not recently (not in the last year)
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut
down?
Yeah, I’ve had a nurse tell me once a couple of months ago.
Patient Readiness to Change: 6
Patient Readiness for Referral: 4
Drug - Complete Case 1
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: chest pain
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? Maybe three years ago at New Years
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? Today
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you use? Ritalin (20mg tabs), usually 4 tabs
How frequently do you use? Daily, more than 4 when extra stressed or tired
Patient Answers to DAST:
These questions refer to the past 12 months.
1.
Have you used drugs other than those required for medical reasons?
Yes
2. Do you abuse more than one drug at a time?
No
3. Are you unable to stop using drugs when you want to?
Yes
4. Have you ever had blackouts or flashbacks as a result of drug use?
No
5. Do you ever feel bad or guilty about your drug use?
Yeah, sometimes
6. Does your spouse (or parents) ever complain about your involvement with drugs?
Yeah, he/she does—all the time
7. Have you neglected your family because of your use of drugs?
Yes, I’ve gotten caught up in what I was doing and forgot things
8. Have you engaged in illegal activities in order to obtain drugs?
No
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
No
10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?
No
Patient Readiness to Change: 4
Patient Readiness for Referral: 1
Alcohol - Complete Case 2
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: epigastric pain
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? This past weekend
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? I don’t use drugs
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you drink? Beer—more than a case a week
How frequently do you drink? A couple (3-4) during the week and a case every weekend
Patient Answers to AUDIT:
1. How often do you have a drink containing alcohol?
4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
Maybe 3 or 4
3. How often do you have six or more drinks on one occasion?
Usually about once a month
4. During the past year, how often have you found that you were not able to stop drinking once you had started?
I only get that way every couple of months (less than monthly)
5. During the past year, how often have you failed to do what was normally expected of you because of drinking?
The same—every couple of months
6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
Every couple of months
7. During the past year, how often have you had a feeling of guilt or remorse after drinking?
Usually about once a month
8. During the past year, have you been unable to remember what happened the night before because you had
been drinking?
Every couple of months
9. Have you or someone else been injured as a result of your drinking?
No
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut
down?
Yeah, my friend is always telling me that I drink too much. (yes, within this year)
Patient Readiness to Change: 6
Patient Readiness for Referral: 8
Drug - Complete Case 2
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: low energy, depressed (not suicidal)
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? Maybe three years ago at New Years
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? Today
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you use? Marijuana, a lot (can’t quantify)
How frequently do you use? Everyday, all day
Patient Answers to DAST:
These questions refer to the past 12 months.
1.
Have you used drugs other than those required for medical reasons?
Yes
2. Do you abuse more than one drug at a time?
No
3. Are you unable to stop using drugs when you want to?
Yes
4. Have you ever had blackouts or flashbacks as a result of drug use?
Yes
5. Do you ever feel bad or guilty about your drug use?
Yeah, I guess
6. Does your spouse (or parents) ever complain about your involvement with drugs?
Yeah, my (spouse or parents) say they worry about me
7. Have you neglected your family because of your use of drugs?
Yes
8. Have you engaged in illegal activities in order to obtain drugs?
Yeah (sell pills for money to buy THC)
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
No
10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?
No
Patient Readiness to Change: 6
Patient Readiness for Referral: 8
Alcohol - Complete Case 3
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: follow-up for fractured humerus
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? Last night
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? I don’t use drugs
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you drink? Liquor drinks, about 2 handles a week (handle = half gallon)
How frequently do you drink? Usually 5-6 drinks every day, more on the weekends
Patient Answers to AUDIT:
1. How often do you have a drink containing alcohol?
4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
Maybe 5 or 6
3. How often do you have six or more drinks on one occasion?
Almost every day
4. During the past year, how often have you found that you were not able to stop drinking once you had started?
Sometimes on the weekends—maybe a couple times a week
5. During the past year, how often have you failed to do what was normally expected of you because of drinking?
Happens most every weekend
6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
Monday’s can be pretty tough so I would say most Monday’s
7. During the past year, how often have you had a feeling of guilt or remorse after drinking?
I guess once a week or so
8. During the past year, have you been unable to remember what happened the night before because you had
been drinking?
Yeah, usually at least once a week
9. Have you or someone else been injured as a result of your drinking?
Yeah, I got in a car accident a few months ago
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut
down?
Yeah, after my accident, my mom told me she thought I was drinking too much.
Patient Readiness to Change: 4
Patient Readiness for Referral: 2
Drug - Complete Case 3
Directions:
Participate as a “patient” by answering the physicians’ questions using the following information.
Reason for visit: vomiting; Hepatitis C positive and have Diabetes
SBIRT 3 Questions—Your Answers
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Do you smoke cigarettes or use other tobacco products? NO
When was the last time you had more than 4 drinks in one day? I don't drink
How many times in the past year have you used an illegal drug or used a prescription medication for
nonmedical reasons? Today
Quantity/Frequency of Use—ONLY PROVIDE IF PHYSICIAN ASKS
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What & how much do you use? Marijuana (a lot) and crack ($300 a week)
How frequently do you use? 4 blunts a day, every day; $100 of crack 3 times a week
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Patient Answers to DAST:
These questions refer to the past 12 months.
1.
Have you used drugs other than those required for medical reasons?
Yes
2. Do you abuse more than one drug at a time?
Yes
3. Are you unable to stop using drugs when you want to?
Yes
4. Have you ever had blackouts or flashbacks as a result of drug use?
Yes
5. Do you ever feel bad or guilty about your drug use?
No
6. Does your spouse (or parents) ever complain about your involvement with drugs?
Yes
7. Have you neglected your family because of your use of drugs?
Yes
8. Have you engaged in illegal activities in order to obtain drugs?
Yeah (has stolen from people in the past)
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
No
10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?
No
Patient Readiness to Change: 7
Patient Readiness for Referral: 4