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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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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
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