Alcohol Screening Questionnaire Template
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1
2Alcohol screening questionnaire (AUDIT)
Patient name: ___________________
Drinking alcohol can affect your health and some medications you
may take. Please help us provide you with the best medical care by
Date of birth: ____________________
answering the questions below.
1.5 oz.
12 oz.
5 oz.
One drink equals:
liquor
beer
wine
(one shot)
2 - 4
2 - 3
4 or more
Monthly
1. How often do you have a drink containing
Never
times a
times a
times a
or less
alcohol?
month
week
week
10 or
2. How many drinks containing alcohol do you have
0 - 2
3 or 4
5 or 6
7 - 9
more
on a typical day when you are drinking?
Daily or
Less than
3. How often do you have four or more drinks on
Never
Monthly
Weekly
almost
monthly
one occasion?
daily
Daily or
4. How often during the last year have you found
Less than
Never
Monthly
Weekly
almost
that you were not able to stop drinking once you
monthly
daily
had started?
Daily or
5. How often during the last year have you failed to
Less than
Never
Monthly
Weekly
almost
do what was normally expected of you because of
monthly
daily
drinking?
Daily or
6. How often during the last year have you needed a
Less than
Never
Monthly
Weekly
almost
first drink in the morning to get yourself going
monthly
daily
after a heavy drinking session?
Daily or
Less than
7. How often during the last year have you had a
Never
Monthly
Weekly
almost
monthly
feeling of guilt or remorse after drinking?
daily
Daily or
8. How often during the last year have you been
Less than
Never
Monthly
Weekly
almost
unable to remember what happened the night
monthly
daily
before because of your drinking?
Yes, but
Yes, in the
9. Have you or someone else been injured because
No
not in the
last year
of your drinking?
last year
Yes, but
10. Has a relative, friend, doctor, or other health
Yes, in the
No
not in the
care worker been concerned about your drinking
last year
last year
or suggested you cut down?
0
1
2
3
4
Never
Currently
In the past
Have you ever been in treatment for an alcohol problem?
I
II
III
IV
M: 0-4
5-14 15-19 20+
W: 0-3
4-12 13-19 20+
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Parent category: Life