Questionnaire: Audit (part of Client Intake) Name First Middle Last Date MM slash DD slash YYYY Please choose the answer that is correct for you1. 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 2. 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 3. How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 4. 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 5. 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 6. 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 7. 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 8. 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 9. 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 10. 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 Δ
