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Date Entered____________

Staff Initials____________

COMBINE
Telephone Quick Screen (TQS ver. B)
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TELEPHONE OR IN-PERSON QUICK SCREEN


Thank you for calling the ___________________________. First may I ask you if youre calling about
yourself or someone else? ____self ___other __________ (list). (If other describe programs briefly and
indicate we need to talk to the patient themselves). We have a variety of programs available at the
[Center], including [fee-for-service clinical treatment programs as well as free treatment research
studies].
We must first ask you some basic questions to help identify the treatment approach that would be
most appropriate for you. You may consider some of this information to be personally sensitive, if you
do not wish to provide this information over the phone, we will be happy to set up an in-person
appointment. Any information you provide will be kept strictly confidential, and it will not be
recorded in any way that will identify you.
Do you wish to continue with this phone interview? ____yes ___no. (If no, either set up an in-person
interview or terminate interview).
Please feel free to interrupt and ask any questions you may have at any point during this interview.
You may also terminate the interview at any time.
Now, I would like to begin the interview. We will start with some preliminary information and
progress on to some questions regarding your living situation, alcohol and drug use history, and
medical history. First, may I ask, how did you hear about us?
Source ________________________

GENERAL INFORMATION
1.

What is your age? (in years at last birthday) ______

2.

What is your gender:


___ (1) Male
___ (2) Female

TQS_9 (9/18/01)

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3.

Do you have permanent address?


___ (0) No
___ (1) Yes

4.

Are you planning to move in the next year?


___ (0) No
___ (1) Yes
___ (8) Dont Know
Where are you going?_______________________________

5.

Do you plan on being away from the area for up to 21 days in a row over the next 16 weeks?
____ (0) No
____ (1) Yes
__________________________________________________________

ALCOHOL HISTORY
NOTE: For answering these questions, one drink is equal to 10 ounces of beer, or 4 ounces of wine, or
1 ounce of liquor.
6.

How often do you have a drink containing alcohol?


(0) NEVER

7.

(4) 4 OR
MORE
TIMES A WEEK
How many drinks containing alcohol do you have on a typical day when you are drinking?
(0) 1 or 2

8.

(1)MONTHLY
OR LESS

(1) 3 or 4

(2) 2 TO 4 TIMES
A MONTH

(2) 5 or 6

(3) 2 - 3 TIMES
A WEEK

(3) 7 to 9

How often do you have six or more drinks on one occasion?


(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
MONTHLY

(4) 10 or More

(4)DAILY OR
ALMOST
DAILY

9.

How often during the last year have you found that you were not able to stop drinking once you
have started?
(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
(4)DAILY OR
MONTHLY
ALMOST DAILY

10.

How often during the last year have you failed to do what was normally expected from you
because of drinking?
(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
(4)DAILY OR
MONTHLY
ALMOST DAILY

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11.

How often during the last year have you needed a first drink in the morning to get yourself
going after a heavy drinking session?
(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
(4)DAILY OR
MONTHLY
ALMOST DAILY

12.

How often during the last year have you had a feeling of guilt or remorse after drinking?
(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
(4)DAILY OR
MONTHLY
ALMOST DAILY

13.

How often during the last year have you been unable to remember what happened the night
before because you had been drinking?
(0)NEVER (1)LESS THAN
(2)MONTHLY
(3)WEEKLY
(4)DAILY OR
MONTHLY
ALMOST DAILY

14.

Have you or someone else been injured as a result of your drinking?


(0) NEVER
(2)YES, BUT NOT IN
(4)YES, DURING
THE LAST YEAR
THE LAST YEAR

15.

Has a relative or friend, or a doctor or other health worker been concerned about your
drinking or suggested you cut down?
(0)NO
(2)YES, BUT NOT IN
(4)YES, DURING
THE LAST YEAR
THE LAST YEAR

Score _________ (score items 5 - 12 as 0, 1, 2, 3, ,4 with 0 being the low end of the scale e.g. Never, 1-2
drinks. For items 13 and 14 score 0, 2 or 4. Add all item scores to arrive at the total score and enter this in
the blank).

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Other questions involving Alcohol and Drug Use:

16.

When was your last drink?

17.

Are you currently or do you plan to engage in other treatment for alcohol problems?
____ (0) No
____ (1) Yes
____ (8) Dont Know

18.

Do you need to report about your progress in treatment to a legal authority or any other entity?
____ (0) No
____ (1) Yes

19.

Are you using opiates or narcotics? (give examples)


____ (0) No
____ (1) Yes

20.

Have you been in an inpatient setting for substance use disorder(s) in the last 30 days?
____ (0) No
____ (1) Yes
a. If yes, for how many days? _____________

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MEDICAL HISTORY
21.

Do you have any medical problems or conditions?


____ (0) No
____ (1) Yes
21a. Specify (i.e., acute vs. chronic) __________________________________________________
___________________________________________________________________________

22.

Do you have hepatitis or cirrhosis?


____ (0) No
____ (1) Yes

23.

Are you taking any medications prescribed by your doctor?


____ (0) No
____ (1) Yes
23a. Specify___________________________________________

24.

Are you taking any over the counter medication(s) or herbal supplements?
____ (0) No
____ (1) Yes
24a. Specify___________________________________________

25.

Do you have any medication allergies/sensitivities?


____ (0) No
____ (1) Yes
25a. Specify________________________________________

26.

Have you ever taken acamprosate or naltrexone (Revia


)?
____ (0) No
____ (1) Yes
26a. When? _________________________
26b. If yes, were you allergic to the medication(s)?
____ (0) No
____ (1) Yes

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[If Female]. Because some of our programs involve medication, may I ask you: are you
currently pregnant or nursing?
____ (0) No
____ (1) Yes
____ (8) Dont Know
27a. [If 27 = (8) or (0)] What birth control measures are you currently using? (Check all that
apply)
____ (1) Barrier methods (foam, condom, diaphragm)
____ (2) Oral contraceptives
____ (3) Implant (Norplant)
____ (4) Tubal ligation
____ (5) Hysterectomy
____ (6) None
____ (7) Refused to answer question
____ (8) Other
27b. If other method, please specify:________________________________

Thank you for your time and your cooperation. Do you have any questions about what we just did?
Inform client of whether they appear to be acceptable for the trial or not. If so, complete the contact sheet
and get their first name, a phone number where you can call them or leave a confidential message (e.g. not a
work phone) and set up an appointment.
If they are not acceptable for this trial, refer them to another project or treatment provider.

OUTCOME OF TELEPHONE SCREEN


28. Screen fail
____ (0) No
____ (1) Yes
29. Screen success, participant will schedule appointment later
____ (0) No
____ (1) Yes
30. Screen success, appointment scheduled
____ (0) No
____ (1) Yes
If ELIGIBLE for cell 10, make a copy of the TQS and mail it to the Coordinating Center. Keep the
original in the individuals CRF binder.
TQS_9 (9/18/01)

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