Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
CAGE Alcohol Screening Questionnaire
Your information
Patient Name *
Date of Birth
____ / ____ / ________
Date of Screening
____ / ____ / ________
Have you felt you should Cut down on drinking?
- Yes
- No
- Not sure
Have people Annoyed you by criticizing your drinking?
Have you felt Guilty about your drinking?
- Yes
- No
- Not sure
Additional details
Have you had a morning Eye-opener drink?
- Yes
- No
- Not sure
Current Drinking Frequency
CAGE Total Score
Clinical Interpretation
Prior Alcohol Treatment History
Provider Notes
CAGE Alcohol Screening Questionnaire template from formisoft.com. formisoft.com/intake-templates/cage-alcohol-screening