AUDIT-C ALCOHOL SCREEN

Date: [Date]
Patient: [Name or ID, age, sex the cutoff is based on]
Format: [Self-completed on paper or tablet, or asked aloud; interpreter if used]
Standard drink used: [The definition where you practice, and the drink sizes the patient described]

ANSWERS
Q1 How often: [Answer and points, 0 to 4]
Q2 Drinks on a typical day: [Answer and points, 0 to 4]
Q3 Six or more on one occasion: [Answer and points, 0 to 4]
Total: [0 to 12]

INTERPRETATION
Cutoff applied: [4 or more for men, 3 or more for women, or your program's cutoff]
Screen: [Negative or positive]
Points from Q1 only: [Yes, with recent intake checked; or no]
Range: [0 to 2, 3, 4 to 7, or 8 to 12, and what it means for this patient]
Last result: [Date and total, or first screen]

FOLLOW-UP
Full AUDIT: [Total of 0 to 40 and the WHO zone, or not done and why]
Brief intervention: [Feedback given, advice, and the patient's own goal; or not needed]
Alcohol use disorder: [DSM-5 criteria met and severity, referral for assessment, or not indicated]
Interactions and risks: [Medicines, conditions, pregnancy, driving, or none]

PLAN
Next step: [Routine rescreen, follow-up visit, referral, or treatment started]
Tests: [Liver tests, blood count, or none]
Rescreen: [Date or interval]

Clinician: [Name, credentials]