Alcohol Baseline Progress Note
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1
2Alcohol Baseline Progress Note
Date:
Time spent:
Patient name:
AUDIT score (if done):
(positive =
8 for men;
4 for women)
≥
≥
Screening question:
Heavy drinking days in the past year
(
5 drinks for men/
4 for women)
days (positive =
1)
≥
≥
≥
Continue if screen is positive:
Average weekly drinking
drinks per week
DSM-IV (revised) symptom criteria:
Abuse—Repeated or persistent problems in any of these ar eas because of drinking?
no
yes role failure
no
yes run-ins with the law
no
yes risk of bodily harm
no
yes relationship trouble
Is
one or more
positive?
no
yes
Alcohol abuse
Dependence—Any of the following symptoms in the past y ear?
no
yes tolerance
no
yes spent a lot of time on
drinking-related activities
no
yes withdrawal
no
yes spent less time on
no
yes not been able to stick to
other matters
drinking limits
no
yes not been able to cut down
no
yes kept drinking despite psychological
or stop in spite of attempts
or physical problems
Are
three or more
positive?
no
yes
Alcohol dependence
Additional history:
Physical examination and laborator y:
Assessment:
Negative alcohol screen
Alcohol abuse
Alcohol withdrawal
At-risk drinking
Alcohol dependence
Plan:
Repeat screening as needed
Patient education about drinking limits
Recommended drinking within limits
Did the patient agree?
yes
no
Recommended abstinence
Did the patient agree?
yes
no
Naltrexone 50 mg daily
Acamprosate 666 mg 3 times daily
Disulfiram 250 mg daily
XR-Naltrexone injectable
Acamprosate 333 mg 3 times daily (for moderate renal impairment)
Thiamine 100 mg IM/PO
Other medication/dosage:
Referral (specify):
Other plan (specify):
Followup:
Excerpted from NIH Publication No. 06-3769
National Institute on Alcohol A buse and Alcoholism
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