Questionnaire
Dear Patient
As part of my service I am examining lifestyle issues likely to 1 standard drink =
affect the health of my patients. This will assist me in giving
the best treatment possible. To help me do this, could you
please complete this questionnaire in the waiting room before
your appointment. When you have finished, please hand it
back to the receptionist. I will explain the results to you during OR OR
your consultation. Your answers to these questions will be
treated in strict confidence. middy of beer small glass of wine nip of spirits
(285mls) (100 mls) (30 mls)
1.5 standard drinks =
Name
OR OR
Age Sex: Male Female
1 schooner 1 can 1 stubby
(425mls) (375 mls) (375 mls)
1. How often do you have a drink containing alcohol?
Never Monthly or less 2–4 times a month 2 to 3 times a week 4 times a week or more
2. How many standard drinks do you have on a day when you are drinking?
1 or 2 3 or 4 5 or 6 7 or 8 10 or more
3. How often do you have 6 or more standard drinks on one occasion?
Never Less than monthly Monthly Weekly Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
Never Less than monthly Monthly Weekly Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of your drinking?
Never Less than monthly Monthly Weekly Daily or almost daily
6. How often during the last year have you needed a drink in the morning to get you going after a heavy drinking session?
Never Less than monthly Monthly Weekly Daily or almost daily
7. How often during the last year have you had a feeling of guilt or regret after drinking?
Never Less than monthly Monthly Weekly Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never Less than monthly Monthly Weekly Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
No Yes, but not in the last year Yes, during the last year
10. Has a friend, relative, doctor or other health worker been concerned about your drinking or suggested you cut down?
No Yes, but not in the last year Yes, during the last year
Office use only
AUDIT Advised Booklet
© World Health Organization 1989
