The Alcohol Use Disorders Identification Test (AUDIT): Self-Report Version

Patient First Name

Patient Middle Name

Patient Last Name

Date

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 check the box that best describes your answer to each question.

1. How often do you have a drink containing alcohol?

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

3. How often do you have six or drinks on one occasion?

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

5. How often during the last year have you failed to do what was normally expected of you because of drinking?

6. How often during the last year have you needed a first drink in the morning to get yourself going after a drinking session?

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

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

9. Have you or someone else been injured because of your drinking?

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

For Reference:

Beer or Cooler

12 oz beer = 1
16 oz (1 pint) = 1.3
22 oz = 2
40 oz = 3.3

Wine

1 glass = 1
1 bottle = 5

Hard liquor (80 proof)

A mixed drink = 1
A pint (16 oz) = 11
A fifth = 17
1.75 L = 39

Patient/Client First Name

Patient/Client Last Name

Patient/Client Signature

Date

Alcohol Screening AUDIT

For Reference:

Wine

﻿Hard liquor (80 proof)

Hard liquor (80 proof)