Alcohol Use Screening Questionnaire
AUDIT
Patient Name
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Date
Today's Date
*
/
Month
/
Day
Year
Date
1. How often do you have a drink containing alcohol?
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
*
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
3. How often do you have six or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
4. During the past year, how often have you found that you were not able to stop drinking once you had started?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
5. During the past year, how often have you failed to do what was normally expected of you because of drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
6. During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
7. During the past year, how often have you had a feeling of guilt or remorse after drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
8. During the past year, how often have you been unable to remember what happened the night before because you had been drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
*
No
Yes, but not in the past year
Yes, during the past year
10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?
*
No
Yes, but not in the past year
Yes, during the past year
Submit
Total Score:
*
Scoring Guideline:
Total Score
Risk
0
Abstainer, never had problems with alcohol
1-7
Low Risk
8-14
Hazardous or harmful alcohol consumption
15 or more
Moderate-severe alcohol use disorder
Should be Empty: