CAGE SCREEN

Date: [Date]
Patient: [Name or ID, age]
How asked: [In conversation during the history, on a written form, or with an interpreter]
Reason: [Routine screening, a positive alcohol screen, or a concern raised by the patient, family, or a test result]

CAGE RESULT
Yes answers: [0 to 4]
Positive letters: [Cut down, annoyed, guilty, eye-opener, or none]
When last true: [For each yes: within the past year, or longer ago]
Result: [Negative at 0 to 1, or positive at 2 or more; note it if your service counts 1 yes as positive]

CURRENT DRINKING
Drinking days: [Days a week, or days in the past month]
Usual amount: [Standard drinks on a drinking day, and what they drink]
Heaviest day: [Most drinks in one day recently, and how often days like that happen]
Weekly total: [Standard drinks a week]
AUDIT-C: [Total 0 to 12 and the cutoff used, or not done]
Other substances: [Tobacco, cannabis, sedatives, opioids, other drugs, or none]

WITHDRAWAL HISTORY
Past withdrawal: [Shakes, sweats, poor sleep, seizures, hallucinations, or confusion after stopping; or none]
Morning drinking: [Drinks soon after waking to settle nerves or a hangover, and how often; or none]
Last drink: [Date and time]

ASSESSMENT
Harms linked to drinking: [Injuries, blood pressure, liver tests, mood, work, family, driving]
Impression: [Lower-risk drinking, unhealthy drinking without signs of dependence, or a likely alcohol use disorder needing full assessment]
Readiness to change: [The patient's own words, and a 0 to 10 rating if used]

BRIEF INTERVENTION
Feedback: [What the results show, tied to the patient's own concerns]
Advice: [What was advised, including any warning about stopping suddenly]
Patient's goal: [Drink less, to a stated amount; stop; or think it over]

PLAN
Next step: [No further action, follow-up visit, full substance use assessment, or planned withdrawal]
Medication: [Naltrexone, acamprosate, or another option offered or started; thiamine; or none]
Tests: [Liver tests, blood count, or others ordered]
Follow-up: [Date or interval, and when to repeat the screen]

Clinician: [Name, credentials]