0 1 2 3 4 Score Alcohol: How often do you have a drink that Monthly or 2-4 times 2-3 times 4+times contains alcohol? less per month per week per week How many standard alcoholic drinks 1-2 3-4 5-6 7-8 10+ do you have on a typical day when you are drinking? How often do you have 6 or more Never Less than Monthly Weekly Daily or standard drinks on one occasion? monthly almost daily If You Score 5 Or More Please Complete The Following Questions Of The Full Audit How often in the last year have you Never Less than Monthly Weekly Daily or found you were not able to stop monthly almost drinking once you had started? daily How often in the last year have you Never Less than Monthly Weekly Daily or failed to do what was expected of monthly almost you because of drinking? daily How often have you needed an Never Less than Monthly Weekly or alcoholic drink in the morning to get monthly almost you going? daily How often in the last year have you Never Less than Monthly Weekly Daily or had the feeling of guilt or regret after monthly almost drinking? daily How often in the last year have you Never Less than Monthly Weekly or not been able to remember what monthly almost happened when drinking the night daily before? Have you or someone else been No Yes, not in Yes, injured as a result of your drinking? the last during the year last year Has a relative/friend/doctor/health No Yes, not in Yes, worker been concerned about your the last during the drinking or advised you to cut down? year last year Total: ..………
Alcohol: 0 1 2 3 4 Score How often do you have a drink that contains alcohol? Monthly or less 2-4 times per month 2-3 times per week 4+times per week How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-8 10+ How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily If You Score 5 Or More Please Complete The Following Questions Of The Full Audit How often in the last year have you found you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often in the last year have you failed to do what was expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often have you needed an alcoholic drink in the morning to get you going? Never Less than monthly Monthly Weekly or almost daily How often in the last year have you had the feeling of guilt or regret after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often in the last year have you not been able to remember what happened when drinking the night before? Never Less than monthly Monthly Weekly or almost daily Have you or someone else been injured as a result of your drinking? No Yes, not in the last year Yes, during the last year Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? No Yes, not in the last year Yes, during the last year Total: ..………
New%20Patient%20Form%202018.docx