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Behavior and Symptom Identification Scale (BASIS-24)

Behavior and Symptom Identification Scale (BASIS-24) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires


BASIS-24
®
(Behavior And Symptom Identification Scale)
ADULT VERSION


Instructions to Staff: Please fill in the following information completely.

Client ID: __ __ __ __ __ __ __ __ __

HCO ID: __ __ __ __

Admission / Intake Date: __ __ /__ __/__ __

Time Point:
1
 Admission/Intake
2
 Mid-treatment
3
 Discharge termination
4
 Post-treatment follow-up




Level of Care:
1
 Inpatient
2
 Outpatient
3
 Partial/day hospital
4
 Residential

Program Type or Unit: __ __
Instructions to Respondents:

This survey asks about how you are feeling and doing in different areas of life. Please check the box to the left of
your answer that best describes yourself during the PAST WEEK. Please answer every question. If you are
unsure about how to answer, please give the best answer you can.

EXAMPLE:
During the PAST WEEK, how much difficulty did
you have…
No
difficulty
A little
difficulty
Moderate
difficulty
Quite a bit
of difficulty
Extreme
difficulty
Ex Sleeping?     



During the PAST WEEK, how much difficulty did
you have…
No
difficulty
A little
difficulty
Moderate
difficulty
Quite a bit
of difficulty
Extreme
difficulty
1 Managing your day-to-day life?     
2 Coping with problems in your life?     
3 Concentrating?     

During the PAST WEEK, how much of the time
did you…
None of
the time
A Little of
the time
Half of the
time
Most of the
time
All of the
time
4 Get along with people in your family?     
5 Get along with people outside your family?     
6 Get along well in social situations?     
7 Feel close to another person?     
8
Feel like you had someone to turn to if you needed
help?
    
9 Feel confident in yourself?     

During the PAST WEEK, how much of the time
did you…
None of
the time
A Little of
the time
Half of the
time
Most of the
time
All of the
time
10 Feel sad or depressed?     
11 Think about ending your life?     
12 Feel nervous?     

During the PAST WEEK, how often did you… Never Rarely Sometimes Often Always
13 Have thoughts racing through your head?     
14 Think you had special powers?     
15 Hear voices or see things?     
16 Think people were watching you?     
17 Think people were against you?     


Copyright McLean Hospital, 2011
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Copyright McLean Hospital, 2011
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During the PAST WEEK, how often did you… Never Rarely Sometimes Often Always
18 Have mood swings?     
19 Feel short-tempered?     
20 Think about hurting yourself?     

During the PAST WEEK, how often… Never Rarely Sometimes Often Always
21
Did you have an urge to drink alcohol or take
street drugs?
    
22
Did anyone talk to you about your drinking or drug
use?
    
23 Did you try to hide your drinking or drug use?     
24
Did you have problems from your drinking or drug
use?
    


ABOUT YOU
25. How old are you? _____

26. What is your sex?
1
Male

2
Female

27. Are you…
1
Hispanic or Latino

2
NOT Hispanic or Latino
28. What is your racial background? (Select one.)
1
American Indian or Alaskan native
2
Asian
3
Black or African-American
4
White/Caucasian
5
Native Hawaiian or other Pacific Islander
6
Multiracial or other (specify)
_______________

32. Where did you sleep in the past 30 days? (Select all
that apply.)
1
Apartment or house
2
Halfway house/group home/board and care
home/residential center/supervised housing
3
School or dormitory
4
Hospital or detox center
5
Nursing home/assisted living
6
Shelter/street
7
Jail/prison
8
Other (fill in)_____________________
29. How much school have you completed?
1
8th grade or less
2
Some high school
3
High school graduate/GED
4
Some college
5
4-year college graduate or higher

33. At any time in the past 30 days, did you work at a
paying job?
1
No
2
Yes, 1 – 10 hours per week
3
Yes, 11 – 30 hours per week
4
Yes, more than 30 hours per week
30. Are you now…
1
Married
2
Separated
3
Divorced
4
Widowed
5
Never married
34. At any time in the past 30 days, did you work at a
volunteer job?
1
No
2
Yes, 1 – 10 hours per week
3
Yes, 11 – 30 hours per week
4
Yes, more than 30 hours per week

35. At any time in the past 30 days, were you a student
in a high school, job training, or college degree
program?
1
Yes
2
No

36. Do you now receive disability benefits; for example,
SSI, SSDI, or other disability insurance (Check one or
more)
1
No
2
Yes, I receive disability for medical reasons
3
Yes, I receive disability for psychiatric reasons
4
Yes, I receive disability for substance abuse

31. Outside of your treatment providers, what is your
main source of social support? (Select all that apply.)
1
Wife, husband, or partner
2
Other family (parents, children, relatives)
3
Friends/roommates
4
Community/church
5
Other
6
No one
37. Today’s Date: __ __ /__ __/__ __


THANK YOU VERY MUCH!
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To Be Completed By Hospital Staff


Program Type (Select one):
1
 General adult
2
 Child/adolescent
3
 Geriatric
4
 Affective/mood disorders
5
 Psychotic disorders
6
 Anxiety disorders/trauma
7
 Substance abuse/chemical dependency/trauma
8
 Dual diagnosis
9
 Other (fill in) ___________________

Primary Payer:
1
 Self pay
2
 BC/BS
3
 Medicaid
4
 Medicare
5
 Commercial
6
 Uninsured Primary payer:

Managed Care/HMO:
1
 Yes
2
 No
3
 Unknown Managed Care/HMO:

Diagnosis
GAF (1 to 100)
Primary Diagnosis
Secondary Diagnosis
Tertiary Diagnosis
AXIS IIa
AXIS IIb

Does patient have a medical condition requiring ongoing treatment?
1
 Yes
2
 No
3
 Unknown

AXIS IV (Select all that apply):
1
 Problems with primary support group
2
 Problems related to the social environment
3
 Educational problems
4
 Occupational problems
5
 Housing problems
6
 Economic problems
7
 Problems with access to health care services
8
 Problems related to interaction with the legal system/crime
9
 Other psychosocial and environmental problems
10
 Not available
Copyright McLean Hospital, 2011
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