Audit Questionnaire

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(800)-213-ETRS | Wayne County: 734-462-3096 | Oakland County: 248-399-2600

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For Clients
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About
Contact

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Audit Questionnaire

Name

First Middle Last

Date

MM slash DD slash YYYY

Please choose the answer that is correct for you

How often do you have a drink containing alcohol

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

How many standard drinks containing alcohol do you have on a typical day when drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

How often do you have six or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, how often have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

During the past year, have you been unable to remember what happened the night before because you had been drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Have you or someone else been injured as a result of your drinking?

No

Yes, but not in the past year

Yes, during the past year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

No

Yes, but not in the past year

Yes, during the past year

The Michigan Alcoholism Screening Test (MAST)

Patient Name

Date

MM slash DD slash YYYY

Please choose either Yes or No for each item as it applies to you

Do you feel you are a normal drinker? (By normal we mean do you drink less than or as much as most other people.)

Yes

No

Have you ever woke up the morning after some drinking the night before and found that you could not remember apart of the evening?

Yes

No

Does your significant other, parent or other near relative ever worry or complain about your drinking?

Yes

No

Can you stop drinking without a struggle after one or two drinks?

Yes

No

Do you ever feel guilty about your drinking?

Yes

No

Do friends or relatives think you are a normal drinker?

Yes

No

Are you able to stop drinking when you want to?

Yes

No

Have you ever attended a meeting of Alcoholics Anonymous (AA) ?

Yes

No

Have you gotten into physical fights when drinking?

Yes

No

Has your drinking ever created aproblem between you and your significant other, aparent, ro any other relative?

Yes

No

Has your significant other (or other family members) ever gone to anyone for help about your drinking?

Yes

No

Have you ever lost friends because of drinking?

Yes

No

Have you ever gotten into trouble at work or school because of drinking?

Yes

No

Have you ever lost a job because of drinking?

Yes

No

Have you ever neglected your obligations, your family or your work for two or more days ni a row because of you were drinking?

Yes

No

Do you drink before noon fairly often?

Yes

No

Have you ever been told you have liver trouble? Cirrhosis?

Yes

No

After heavy drinking have you ever had Delirium Tremens (DTs') or severe shaking, or heard voices or seen things that really were not there?

Yes

No

Have you ever gone to anyone for help about your drinking?

Yes

No

Have you ever been in a hospital because of drinking?

Yes

No

Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem that resulted in hospitalization?

Yes

No

Have you ever been seen at apsychiatric or mental health clinic, or gone to any doctor, social worker, or clergyman for help with an emotional problem, where drinking was part of the problem?

Yes

No

Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages?

Yes

No

If YES, how many times

Have you ever been arrested, or taken into custody even for a few hours, because of other drunk behavior

Yes

No

If YES, how many times

DAST (Drug Abuse Screening Test)

Name

First Middle Last

Date

MM slash DD slash YYYY

Instructions: CIRCLE the word "yes" or "no", which you honestly feel describes your position ni regard to each of the questions below. The key to answering the questions... HONESTY

Have you used drugs other than those required for medical reasons?

Yes

No

Have you ever abused prescription drugs?

Yes

No

Do you abuse more than one drug at a time?

Yes

No

Can you get through the week without using drugs (other than those used for medical reasons)?

Yes

No

Are you always able ot stop using drugs when you want to?

Yes

No

Do you try ot limit your drug use to certain situations?

Yes

No

Have you had "blackouts" or "flashbacks" as a result of drug use?

Yes

No

Do you ever feel bad about your drug abuse?

Yes

No

Does your spouse (or parents) ever complain about your involvement with drugs?

Yes

No

Do your friends or relatives know or suspect you abuse drugs?

Yes

No

Has drug abuse ever created problems between you and your spouse?

Yes

No

Has any family member ever sought help for problems related to your drug use?

Yes

No

Have you ever lost friends because of your use of drugs?

Yes

No

Have you ever neglected your family or missed work because of your drug use?

Yes

No

Have you ever been in trouble at work because of drug abuse?

Yes

No

Have you ever lost a job because of drug abuse?

Yes

No

Have you gotten into fights when under the influence of drugs?

Yes

No

Have you ever been arrested because of unusual behavior while under the influence of drugs?

Yes

No

Have you ever been arrested for driving while under the influence of drugs?

Yes

No

Have you engaged in illegal activities to obtain drugs?

Yes

No

Have you ever been arrested for possession of ilegal drugs?

Yes

No

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)?

Yes

No

Have you ever gone to anyone for help for a drug problem?

Yes

No

Have you ever been in the hospital for medical problems related to your drug use?

Yes

No

Have you ever been involved in a treatment program specifically related to drug use?

Yes

No

Have you ever been treated as an outpatient for problems related to drug abuse?

Yes

No

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