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.

1.5 oz.
12 oz. 5 oz.
One drink equals: wine
liquor
beer (one shot)

Two to Two to Four or

1. How often do you have a drink containing Monthly four three more
Never
alcohol? or less times a times a times a
month week week
2. How many drinks containing alcohol do you
Zero to Three or Five or Seven to Ten or
have on a typical day when you are
two four six nine more
drinking?
Daily or
3. How often do you have six or more drinks Less than
Never Monthly Weekly almost
on one occasion? monthly
daily
4. How often during the last year have you Daily or
Less than
found that you were not able to stop drinking Never Monthly Weekly almost
monthly
once you had started? daily
5. How often during the last year have you Daily or
Less than
failed to do what was normally expected of Never Monthly Weekly almost
monthly
you because of drinking? daily
6. How often during the last year have you
Daily or
needed a first drink in the morning to get Less than
Never Monthly Weekly almost
yourself going after a heavy drinking monthly
daily
session?
Daily or
7. How often during the last year have you had Less than
Never Monthly Weekly almost
a feeling of guilt or remorse after drinking? monthly
daily
8. How often during the last year have you Daily or
Less than
been unable to remember what happened the Never Monthly Weekly almost
monthly
night before because of your drinking? daily
Yes, but Yes, in
9. Have you or someone else been injured
No not in the the last
because of your drinking?
last year year
10. Has a relative, friend, doctor, or other Yes, but Yes, in
health care worker been concerned about No not in the the last
your drinking or suggested you cut down? last year year

0 1 2 3 4

I II III IV
0 8 16 20
 For clinician:
Clinician Name:____________________________ Date: _______________AUDIT Zone: ___________

Brief intervention: Raised subject Not done Referral recommended

Provided feedback (consider using Oregon referral
Enhanced motivation line: 1-800-923-4357)
Negotiated plan
STABLE RESOURCE TOOLKIT

AUDIT-C - Overview

The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous
drinkers or have active alcohol use disorders (including alcohol abuse or dependence).
The AUDIT-C is a modified version of the 10 question AUDIT instrument.

Clinical Utility
The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous
drinkers or have active alcohol use disorders.

Scoring
The AUDIT-C is scored on a scale of 0-12.
Each AUDIT-C question has 5 answer choices. Points allotted are:
a = 0 points, b = 1 point, c = 2 points, d = 3 points, e = 4 points
n In men, a score of 4 or more is considered positive, optimal for identifying hazardous
drinking or active alcohol use disorders.
n In women, a score of 3 or more is considered positive (same as above).
n However, when the points are all from Question #1 alone (#2 & #3 are zero), it can be
assumed that the patient is drinking below recommended limits and it is suggested that the
provider review the patients alcohol intake over the past few months to confirm accuracy.3
n Generally, the higher the score, the more likely it is that the patients drinking is affecting his
or her safety.

Psychometric Properties
For identifying patients with heavy/hazardous drinking and/or Active-DSM alcohol
abuse or dependence
Men1 Women2
3 Sens: 0.95 / Spec. 0.60 Sens: 0.66 / Spec. 0.94
4 Sens: 0.86 / Spec. 0.72 Sens: 0.48 / Spec. 0.99

For identifying patients with active alcohol abuse or dependence

3 Sens: 0.90 / Spec. 0.45 Sens: 0.80 / Spec. 0.87
4 Sens: 0.79 / Spec. 0.56 Sens: 0.67 / Spec. 0.94

1. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT Alcohol Consumption Questions (AUDIT-C): An effective
brief screening test for problem drinking. Arch Internal Med. 1998 (3): 1789-1795.
2. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests from the Alcohol Use Disorders
Identification Test (AUDIT): Validation in a female veterans affairs patient population. Arch Internal Med Vol
163, April 2003: 821-829.
3. Frequently Asked Questions guide to using the AUDIT-C can be found via the website:
www.oqp.med.va.gov/general/uploads/FAQ%20AUDIT-C
STABLE RESOURCE TOOLKIT

AUDIT-C Questionnaire

Patient Name ______________________________________ Date of Visit ________________

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

a. Never
b. Monthly or less
c. 2-4 times a month
d. 2-3 times a week
e. 4 or more times a week

2. How many standard drinks containing alcohol do you have on a typical day?
a. 1 or 2
b. 3 or 4
c. 5 or 6
d. 7 to 9
e. 10 or more

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

a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily

AUDIT-C is available for use in the public domain.

Drug Screening Questionnaire (DAST)
Using drugs 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.

Which recreational drugs you have used in the past year?

methamphetamines (speed, crystal) cocaine
cannabis (marijuana, pot) narcotics (heroin, oxycodone, methadone, etc.)
inhalants (paint thinner, aerosol, glue) hallucinogens (LSD, mushrooms)
tranquilizers (valium) other ______________________________

1. Have you used drugs other than those required for medical
No Yes
reasons?

2. Do you abuse more than one drug at a time? No Yes

3. Are you unable to stop using drugs when you want to? No Yes

4. Have you ever had blackouts or flashbacks as a result of

No Yes
drug use?

5. Do you ever feel bad or guilty about your drug use? No Yes

6. Does your spouse (or parents) ever complain about your

No Yes
involvement with drugs?
7. Have you neglected your family because of your use of
No Yes
drugs?
8. Have you engaged in illegal activities in order to obtain
No Yes
drugs?
9. Have you ever experienced withdrawal symptoms (felt
No Yes
sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your drug
No Yes
use (e.g. memory loss, hepatitis, convulsions, bleeding)?
0 1

0 1 3 6
I II III IV
 For clinician:
Clinician Name:____________________________ Date: _______________DAST Zone: ___________

Brief intervention: Raised subject Not done Referral recommended

Provided feedback (consider using Oregon referral
Enhanced motivation line: 1 (800) 923-4357)
Negotiated plan