Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Substance Use Screening (CAGE-AID)
Your information
Full Name *
Have you felt you should cut down?
- Yes
- No
- Not sure
Have people annoyed you about your use?
Have you felt guilty about your use?
- Yes
- No
- Not sure
Have you used first thing in the morning?
- Yes
- No
- Not sure
Alcohol Use Frequency
Additional details
Drug Use Frequency
Tobacco/Nicotine Use
Impact on Daily Life
Readiness for Change
Confidentiality Acknowledgment
Substance Use Screening (CAGE-AID) template from formisoft.com. formisoft.com/intake-templates/substance-use-screening