Social Adjustment Scale - Ii: I. Instrumental Role Determination

SOCIAL ADJUSTMENT SCALE – II
Score Sheet
Patient Name: Patient I.D. # Date: ________________
Rater Initial: __ __ __ Assessment: ______
I. Instrumental Role Determination

1. Instrumental Role
Circle
Yes No
A) Student 1 2
B) Homemaker 1 2
C) Worker 1 2
II Worker
2. Working Status _____
3. Scheduled Work _____
4. Time Lost (work) _____
5. Performance Adequacy (work) _____
6. Feelings of Adequacy (work) _____
7. Friction (work) _____
8. Distress (work) _____
9. Likes _____
10. Interest _____
11. Desire for work _____
III Homemaker
a) Will homemaker items be asked? (circle) Yes 1 No 2
12. Homemaker Status _____

13. Time Lost (homemaker) _____
14. Performance Adequacy (homemaker) _____
15. Feelings of Adequacy (homemaker) _____
16. Friction (homemaker) _____
17. Distress _____
18. Likes _____
19. Interest _____
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IV Student
a) Will student items be asked? (circle) Yes 1 No 2
20. Student status _____

21. Time Lost (student) _____
22. Performance Adequacy (student) _____
23. Feelings of Adequacy (student) _____
24. Friction (student) _____
25. Distress _____
26. Likes _____
27. Interest _____
V. Chores
a) Will chore items be asked? (circle) Yes 1 No 2
28. Performance Adequacy _____

29. Feelings of Adequacy _____
30. Friction (chores) _____
31. Distress (chores) _____
32. Likes _____
33. Interest _____
VI Patient’s Finances
34. Income Source _____

35. Economic Adequacy _____
VII Principal Household Member (PFM)

a) Will PFM items be asked? (circle) Yes 1 No 2
36. PFM Designation _____

37. Communication _____
38. Friction _____
39. Adaptability _____
40. Independence _____
41. Expressed feelings _____
VIII Extended Family

a) Will extended family questions be asked?(circle) Yes 1 No 2
42. Contact (extended family) _____

43. Independence (extended family) _____
44. Friction (extended family) _____
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IX Concern For Family Members
a) Will concern questions be asked? (circle) Yes 1 No 2
45. Worry for family members _____

46. Guilt _____
47. Wronged _____
X Social Leisure
48. Leisure activities _____

49. Frequency social contact _____
50. Degree of activity (social) _____
51. Obstacles _____
52. Social Comfort _____
XI Interpersonal Contacts
53. Frequency contact (friends) _____

54. Communication _____
55. Friction (friends) _____
56. Sensitivity _____
XII Romantic Involvement

a) Will romantic items be asked? (circle) Yes 1 No 2
57. Frequency of romantic contacts _____

58. Interest _____
59. Problems (romance) _____
XIII Sexual Adjustment
60. Interest _____

61. Frequency _____
62. Problems _____
XIV. Personal Well-Being
63. Physical health and care _____

64. Personal Appearance and Grooming _____
65. Loneliness _____
66. Self-Appraisal _____
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XV. Globals Yes 1 No 2
67. Instrumental role performance _____

68. PFM _____
69. Extended family _____
70. Social/Leisure _____
71. Intimate interpersonal relations _____
72. Personal well-being _____
73. General adjustment _____
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VOMI SOCIAL ADJUSTMENT SCALE
Answer Sheet
Patient Initial: __ __ __ Patient I.D. # Date: ________________
Rater Initial: __ __ __ ID#: __ __ __ Occasion: ______
Interview Outcome:
1- Interview Conducted Successfully 2- PT Declined Interview 3 – PT left study 4 – Other _______________________
I. Instrumental Role Determination

1. Instrumental Role
Circle
Yes No
A) Student 1 2
B) Homemaker 1 2
C) Worker 1 2
II Worker
2. Working Status _____
3. Scheduled Work _____
4. Time Lost (work) _____
5. Performance Adequacy (work) _____
6. Feelings of Adequacy (work) _____
7. Friction (work) _____
8. Distress (work) _____
9. Likes _____
10. Interest _____
11. Desire for work _____
III Homemaker
a) Will homemaker items be asked? (circle) Yes 1 No 2
12. Homemaker Status _____

13. Time Lost (homemaker) _____
14. Performance Adequacy (homemaker) _____
15. Feelings of Adequacy (homemaker) _____
16. Friction (homemaker) _____
17. Distress _____
18. Likes _____
19. Interest _____
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SOCIAL ADJUSTMENT SCALE – II

Patient Name: Patient I.D. # Date: ________________

Rater Initial: __ __ __ Assessment: ______

I. Instrumental Role Determination

12. Homemaker Status _____

20. Student status _____

28. Performance Adequacy _____

34. Income Source _____

VII Principal Household Member (PFM)

36. PFM Designation _____

VIII Extended Family

42. Contact (extended family) _____

45. Worry for family members _____

48. Leisure activities _____

53. Frequency contact (friends) _____

XII Romantic Involvement

57. Frequency of romantic contacts _____

XIII Sexual Adjustment

60. Interest _____

XIV. Personal Well-Being

63. Physical health and care _____

67. Instrumental role performance _____

Patient Initial: __ __ __ Patient I.D. # Date: ________________

Rater Initial: __ __ __ ID#: __ __ __ Occasion: ______

I. Instrumental Role Determination

12. Homemaker Status _____

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Rater Initial: Assessment: ____

Patient Initial: Patient I.D. # Date: ______________

Rater Initial: ID#: Occasion: ______