Optional Health Assessment Modules Form Page 14
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27OPTIONAL MODULE 6:
UR Number:
GAMBLING
Surname:
Given name:
(PGSI)
Date of birth:
(Please fill in if no label available)
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
To obtain a better understanding of the client’s possible gambling issues.
“Now I’m going to ask you a series of questions in order to get a detailed
picture of your gambling, and how it affects your life.”
WHO CAN ADMINISTER THIS MODULE?
INSTRUCTIONS
This module can be self-administered by the client or administered by a
1. Circle appropriate responses.
clinician.
2. Tally up scores.
3. Consider intervention or referral to a gambling service if there is a
moderate risk or screen indicates that the client is a problem gambler.
IN THE LAST 12 MONTHS HOW OFTEN HAVE YOU...?
NEVER
SOMETIMES
MOST OF
ALMOST
THE TIME
ALWAYS
Bet more than you could afford to lose?
0
1
2
3
Needed to gamble with larger amounts of money to get the same feeling of
0
1
2
3
excitement?
Gone back another day to try and win back the money you lost?
0
1
2
3
Borrowed money or sold anything to get money to gamble?
0
1
2
3
Felt that you might have a problem with gambling?
0
1
2
3
Felt that gambling has caused you health problems, including stress and
0
1
2
3
anxiety?
People criticized your betting or told you that you have a gambling problem,
0
1
2
3
whether or not you thought it was true?
Felt your gambling has caused financial problems for you or your household?
0
1
2
3
Felt guilty about the way you gamble or what happens when you gamble?
0
1
2
3
TOTAL SCORE:
1-2 Low risk
3-7 Moderate risk
8-27 Problem gambler
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
13
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