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Screening

AUDIT Alcohol Screening Form

1 page•12 fields•HIPAA-ready
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AUDIT Alcohol Screening Form

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Patient Name
Jane Martinez
Date of Screening
03/15/1985
Drinking Frequency
Never
Sometimes
Often
Always
Typical Drinks Per Session
Option A
Option B
Option C
Binge Drinking Frequency
Never
Sometimes
Often
Always
Unable to Stop Drinking
Option A
Option B
Option C
Failed Expectations Due to Drinking
Option A
Option B
Option C
Morning Drinking
Option A
Option B
Option C
Guilt After Drinking
Option A
Option B
Option C
Blackouts from Drinking
Option A
Option B
Option C
AUDIT Total Score
0
Risk Level and Recommendation
Select an option...
Submit
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Sign up and start customizing in minutes.

The AUDIT Alcohol Screening Form implements the World Health Organization's Alcohol Use Disorders Identification Test, a validated 10-item screening instrument developed to identify patients with hazardous or harmful alcohol consumption patterns. Each question uses a standardized response scale that assesses drinking frequency, typical quantity, binge episodes, impaired control, morning drinking, guilt, blackouts, alcohol-related injuries, and external concern about the patient's drinking habits.

The form includes automated scoring zones that categorize patients into risk tiers: low risk, hazardous use, harmful use, and possible dependence. Each zone is linked to recommended clinical interventions ranging from alcohol education for low-risk scores to brief intervention for hazardous use and referral for specialist evaluation at higher risk levels. This tiered approach supports the SBIRT (Screening, Brief Intervention, and Referral to Treatment) framework widely adopted in healthcare.

Suitable for primary care practices, emergency departments, behavioral health clinics, occupational health programs, and any clinical setting conducting routine substance use screening. The AUDIT is one of the most widely researched alcohol screening tools globally and is recommended by SAMHSA, USPSTF, and numerous medical specialty organizations for integration into standard clinical workflows.

What's included

  • Complete 10-item WHO AUDIT questionnaire
  • Standardized frequency and quantity response scales
  • Automated risk-zone scoring and categorization
  • SBIRT-aligned intervention recommendations per score
  • Patient demographic and screening date fields
  • Provider notes and referral documentation section

Who uses this template

  • Routine alcohol screening in primary care annual exams
  • Emergency department substance use assessment
  • SBIRT program implementation at community health centers
  • Occupational health and pre-employment screening

All form fields

12 fields across 1 page. Customize any field after signing up.

Patient NameText
Date of ScreeningDate
Drinking FrequencyMultiple Choice
Typical Drinks Per SessionMultiple Choice
Binge Drinking FrequencyMultiple Choice
Unable to Stop DrinkingMultiple Choice
Failed Expectations Due to DrinkingMultiple Choice
Morning DrinkingMultiple Choice
Guilt After DrinkingMultiple Choice
Blackouts from DrinkingMultiple Choice
AUDIT Total ScoreNumber
Risk Level and RecommendationDropdown

How to use the AUDIT Alcohol Screening Form

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the AUDIT Alcohol Screening Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.

Setup steps

  1. 1Choose the template. Find the AUDIT Alcohol Screening Form in the template library and click “Use this template” to add it to your account.
  2. 2Customize fields. Add, remove, or reorder any of the 12 fields. Set fields as required or optional based on your practice needs.
  3. 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
  4. 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
  5. 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.

Frequently asked questions

Is the AUDIT Alcohol Screening Form HIPAA compliant?

Yes. All Formisoft templates, including the AUDIT Alcohol Screening Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.

Can I customize the fields in this template?

Absolutely. You can add, remove, reorder, or modify any of the 12 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

How do patients fill out this form?

Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.

Can I send this form automatically before appointments?

Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.

Does this template work on mobile devices?

Yes. The AUDIT Alcohol Screening Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.

8 min saved per patient98% patient satisfaction3x faster than paper

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