AUDIT RESULT

Date: [Date]
Patient: [Name or ID, age, sex]
Given as: [Interview or self-report questionnaire; language, and interpreter if used]
Why given: [Positive AUDIT-C, intake, admission, or a problem that may be linked to drinking]
Drink size used: [Grams in a standard drink where you practice, and what the patient usually drinks]

ITEM SCORES
Consumption, items 1 to 3: [Points for each, and the subtotal out of 12]
Dependence, items 4 to 6: [Points for each, and the subtotal out of 12]
Harm, items 7 to 10: [Points for each, and the subtotal out of 16]
Skips followed: [None, after item 1, or after items 2 and 3]
Total: [0 to 40]

ZONE
Cutoff: [8, or 7 for a woman or a man over 65, or the program's own]
WHO zone: [I alcohol education, II simple advice, III brief counseling and monitoring, or IV referral]
Moved up a zone: [Yes, for 2 or more on item 4, 5, or 6, or 4 on item 9 or 10; or no]
Earlier results: [Date and AUDIT or AUDIT-C total, or none on file]

ITEMS OF NOTE
Signs of dependence: [What items 4 to 6 describe, and how often]
Withdrawal: [Last drink, last alcohol-free day, past shakes, sweats, seizures, or confusion]
Harms: [Guilt, memory loss, injuries, and who has raised concern]
Past problems: [Item 9 or 10 answered yes, but not in the last year; or none]

INTERVENTION
Given today: [Education, simple advice, brief counseling, or referral, and how long]
Feedback: [What the score means for this patient, tied to their own health]
DSM-5 review: [Criteria met and severity, or not assessed and why]
Patient's goal: [A stated limit, alcohol-free days, stopping, or not ready]

PLAN
Withdrawal plan: [Not needed, or supervised withdrawal, setting, thiamine, and monitoring]
Medicines: [Naltrexone, acamprosate, or another option offered, started, or declined]
Referral: [Service and appointment date, or none]
Bloods: [Liver enzymes, GGT, full blood count, or none ordered]
Review: [Date of the next visit, and when to repeat the AUDIT]

Clinician: [Name, credentials]