Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
AUDIT Alcohol Screening Form
Your information
Patient Name *
Date of Screening
____ / ____ / ________
Drinking Frequency
Typical Drinks Per Session
Binge Drinking Frequency
Unable to Stop Drinking
Additional details
Failed Expectations Due to Drinking
Morning Drinking
Guilt After Drinking
Blackouts from Drinking
AUDIT Total Score
Risk Level and Recommendation
AUDIT Alcohol Screening Form template from formisoft.com. formisoft.com/intake-templates/audit-alcohol-screening