Based on the Alcohol Use Disorders Identification
Test (AUDIT)
Select the choice that
best describes your answer for the period covering
the past 12 months.
1. How
often do you have a drink containing alcohol? (days
a week)
2. How many drinks* containing
alcohol do you have on a typical day when you are drinking?
3. For women: How often do
you have 4 or more drinks a day?5 or more drinks a day?
4. How often during the last
year have you found that you were not able to stop
drinking once you started?
5. How often during the last
year have you failed to do what was normally expected
from you because of drinking?
6. How often during the last
year have you needed a first drink in the morning to
get yourself going after a heavy drinking session?
7. How often during the last
year have you had a feeling of guilt or remorse after
drinking?
8. How often during the last
year have you been unable to remember what happened
the night before because you had been drinking?
9. Have you or someone else
been injured as a result of your drinking?
10. Has a relative or a friend
or a doctor or other health worker been concerned about
your drinking or suggested that you cut down?
11. Are you currently taking
any medications (over the counter or prescription)?
12. At any time in his/her
life, has your father, mother, sister, or brother ever
been an alcoholic or problem drinker?
13. Are you pregnant, breastfeeding,
or planning a pregnancy?
14. Alcohol Treatment History:
(check all that apply)
15. Do you have a medical or
mental health condition?
16. Age
:
17. Sex
:
18. Ethnic/Racial Group (check
all that apply)
19. County of Residence :
20. Zip
Code :
21. Are you currently a student?
22. Highest Level of Education
Completed :
23. This question is for research
purposes only.
