Alcohol Screening Questionnaire Template (Page 2 of 2) in pdf

(For the provider or behavioral health specialist)

Scoring and interpreting the AUDIT:

1. Each response has a score ranging from 0 to 4. All response scores are added for a total score.

2. The total score correlates with a zone of use, which can be circled on the bottom left corner.

Score*

Zone

Action

0-3: Women

I – Low Risk

Brief education

0-4: Men

4-12: Women

II – Risky

Brief intervention

5-14: Men

13-19: Women

Brief intervention or

III – Harmful

15-19: Men

Referral to specialized treatment

20+: Men

IV – Severe

Referral to specialized treatment

20+: Women

Brief education: An opportunity to educate patients about low-risk consumption levels and the risks of

excessive alcohol use.

Brief intervention: Patient-centered discussion that employs Motivational Interviewing concepts to raise

an individual’s awareness of his/her substance use and enhancing his/her motivation towards behavioral

change. Brief interventions are typically performed in 3-15 minutes, and should occur in the same session

as the initial screening. Repeated sessions are more effective than a one-time intervention.

The recommended behavior change is to cut back to low-risk drinking levels unless there are other

medical reasons to abstain (liver damage, pregnancy, medication contraindications, etc.).

Patients with numerous or serious negative consequences from their drinking, or patients with likely

dependence who cannot or will not obtain conventional specialized treatment, should receive more

numerous and intensive interventions with follow up. The recommended behavior change in this case is to

either cut back to low-risk drinking levels or abstain from use.

Referral to specialized treatment: A proactive process that facilitates access to specialized care for

individuals who have been assessed to have substance use dependence. These patients are referred to

alcohol and drug treatment experts for more definitive, in-depth assessment and, if warranted, treatment.

The recommended behavior change is to abstain from use and accept the referral.

More resources:

* Johnson J, Lee A, Vinson D, Seale P. “Use of AUDIT-Based Measures to Identify Unhealthy Alcohol Use and Alcohol

Dependence in Primary Care: A Validation Study.” Alcohol Clin Exp Res, Vol 37, No S1, 2013: pp E253–E259

Alcohol Screening Questionnaire Template Page 2