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Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Gambling
For the purpose of these questions, “gambling” means buying lottery tickets, gambling at a casino, playing cards or dice for money, betting on sports games, playing slot machines, video poker or other video gambling, gambling on the internet, betting on horses or dogs, playing bingo or keno.
* During the past 12 months how many times have you gambled?    
If the answer is 5 or more, then proceed to the following questions:
During the past 12 months, Have you ever felt restless, on edge or irritable when trying to stop or cut down on gambling?
1 - Yes   0 - No  
During the past 12 months, Have you had to ask other people for money to help deal with financial problems that had been caused by gambling?
1 - Yes   0 - No  
During the past 12 months, Have you tried to hide how much you have gambled from your family or friends?
1 - Yes   0 - No  
During the past 12 months, Have you tried to cut down or stop your gambling?
1 - Yes   0 - No  
During the past 12 months, Have you increased your bet or how much you would spend, in order to feel the same kind of excitement as before?
1 - Yes   0 - No  
During the past 12 months, Did you think about gambling even when you were not doing it? (Remembering past gambling experiences, or planning future gambling?)
1 - Yes   0 - No  
During the past 12 months, Did you go to gamble when you were feeling down, stressed, angry or bored?
1 - Yes   0 - No  
During the past 12 months, Did you ever try to win back the money that you had recently lost?
1 - Yes   0 - No  
During the past 12 months, Has your gambling caused problems in your relationships or with work?
1 - Yes   0 - No  
Total “Yes” Responses    
SBIRT
Drinking alcohol and using drugs other than those required for medical reasons can affect your health. These activities can also affect the medications you take. Please help us provide you with the best possible medical care by answering these questions below.

Alcohol:
One drink=12 oz. beer
One drink=5 oz. wine
One drink=1.5 oz. liquor (one shot)
MALE: In the past year have you had 5 or more drinks in a day?
No   Yes  
FEMALE: In the past year have you had 4 or more drinks in a day?
No   Yes  
OVER 65 YEARS: In the past year have you had 4 or more drinks in a day?
No   Yes  
Examples of drugs may include: methamphetamines (speed, crystal); cannabis (marijuana, pot); inhalants (paint thinner, aerosols, glue(; benzodiazepines (valium); barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms); narcotics (opioids); or synthetic cannabinoids (K2, spices) and cathinones (bath salts).
In the past year have you used an illegal drug or a prescription medication for non-medical reasons?
No   Yes  
SBIRT Score:
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