Patient Name *

Phone Number *

Email Address *

1. How often do you have a drink containing alcohol?
NeverMonthly or less2-4 times a month2-3 times a week4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?
0-23 or 45 or 67-910 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?
NoYes, but not in the last yearYes, in the last year

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
NoYes, but not in the last yearYes, in the last year

11. Have you ever been in treatment for an alcohol problem?
NeverCurrentlyIn the past