Alcohol screening questionnaire (AUDIT)

Alcohol screening questionnaire (AUDIT)

Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below:
Name

First NameLast Name
Date of birth

MonthDayYear
Date
One Drink of the following equals:

One drink of Beer = 12 oz

One drink of Wine = 5 oz

One drink of Liquor = 1.5 oz or One shot
1. How often do you have a drink containing alcohol?

NeverMonthly or less2-4 times a month2-3 time a week4 or more times a week
2. How many drink containing alcohol do you have on a typical day when you are drinking?

0-23 or 45 or 67-910 or more
3. How often do you have five or more drinks on one occasion?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
9. Have you or someone else been injured because of your drinking?

NoYes, but not in the last yearYes, in the last year
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

NoYes, but not in the last yearYes, in the last year
Have you ever been in treatment for an alcohol problem?

NeverCurrentlyIn the past
Type a question
Should be Empty: