Dr. Gerald B Harris, II

Patient Name * Date of Birth * Date *

AUDIT Screening Test

Drink Definitions - Some items below ask questions about how many drinks you have had. For the purpose of this screening test, a drink is defined as follows: 1) a single small (8oz; 1/2 pint) glass of beer 2) a single shot/measure of liquor/spirits 3) a single glass of wine.

How often do you have a drink containing alcohol? How many drinks containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more drinks on one occasion? How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected of you because of drinking? How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or someone else been injured as a result of your drinking? Has a relative, friend, or doctor been concerned about your drinking or suggested you cut down?