Audit C.MAT

1

Patient Name* This field is required.

First Name

Last Name

2

UniqueID* This field is required.

3

Email

example@example.com

4

How often do you have a drink containing alcohol?* This field is required.

Never

Monthly or less

2-4 times/ month

2-3 times/ week

4 or more times/ week

7

Screening Test

8

Date

9

ScoreAUDIT_C: >=4 is positive in men; >=3 is positive in women

10

Today's Provider* This field is required.

11

Grading

12

ALERT