REV 8/7/18 YOUR NAME:___________________________________ DATE: ___________________ DOB: _________________ Alcohol Use Disorders Identification Test (AUDIT) Please respond to questions about your use of alcoholic beverages. Standard drink sizes are shown in the pictures below. Place an X in one box that best describes your answer to each question. 0 1 2 3 4 2 to 3 1. How often do you have a drink containing Monthly or 2 to 4 times 4 or more Never times a alcohol? less a month times a week week 2. How many drinks containing alcohol do you have on a typical day when you are 1 or 2 3 or 4 5 or 6 7 to 9 10 or more drinking? Less than Daily or 3. How often do you have five or more drinks Monthly Weekly on one occasion? monthly almost daily 4. How during the last year have you Less than Daily or Never Monthly Weekly found that you were not able to stop drinking monthly almost daily once you had started? 5. How often during the last year have you Less than Daily or failed to do what was normally expected of Never Monthly Weekly monthly almost daily you because of drinking? 6. How during the last year have you Less than Daily or needed a first drink in the morning to get Never Monthly Weekly monthly almost daily yourself going after a heavy drinking session? 7. How often during the last year have you Less than Daily or had a feeling of guilt or remorse after Monthly Weekly monthly almost daily drinking? 8. How often during the last year have you Less than Daily or been unable to remember what happened the Monthly Weekly monthly almost daily night before because of your drinking? Yes, but not 9. Have you or someone else been injured Yes, during No in the last because of your drinking? the last year year 10. Has a relative, friend, doctor, or other Yes, but not Yes, during health care worker been concerned about No in the last the last year your drinking or suggested you cut down? year 11. Do you use other drugs? (e.g. Heroin, Never Daily Weekly Monthly Marijuana, Cocaine)
REV 8/7/18 YOUR NAME:___________________________________ DATE: ___________________ DOB: _________________ Alcohol Use Disorders Identification Test (AUDIT) Please respond to questions about your use of alcoholic beverages. Standard drink sizes are shown in the pictures below. Place an X in one box that best describes your answer to each question. 0 1 2 3 4 1. How often do you have a drink containing alcohol? Never Monthly or less 2 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 2 3 or 4 5 or 6 7 to 9 10 or more 3. How often do you have five or more drinks on one occasion? Less than monthly Monthly Weekly Daily or almost daily 4. How during the last year 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. How often during the last year 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. How during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Less than monthly Monthly Weekly Daily 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? Less than monthly Monthly Weekly Daily 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 11. Do you use other drugs? (e.g. Heroin, Marijuana, Cocaine) Never Daily Weekly Monthly
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