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CLINICIAN SUPPORT MATERIALS

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest.

Place an X in one box that best describes your answer to each question.

Screening Support Materials
Questions01234 
1. How often do you have a drink containing alcohol?
NeverMonthly or less2 to 4
times a month
2 to 3
times a week
4 or more
times a week
 
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 23 or 4 5 or 67 to 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?
No Yes, but not in the last year Yes, during the last year  
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
No Yes, but not in the last year Yes, during the last year  
Total
 

Note: This questionnaire (the AUDIT) is reprinted with permission from the World Health Organization. To reflect standard drink sizes in the United States, the number of drinks in question 3 was changed from 6 to 5. A free AUDIT manual with guidelines for use in primary care settings is available online at www.who.org.

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