| RPT |
.|.|Alcohol Use Disorders Identification Test||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
verified for accuracy and used in conjunction with other diagnostic activities.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|| AUDIT Score: <-AUDIT->| |
Questions and Answers||1. How often do you have a drink containing alcohol? | <*Answer_89*>|2. How many drinks containing alcohol do you have on a typical day when you are drinking?
| <*Answer_90*>|3. How often do you have six or more drinks on one occasion? | <*Answer_91*>|4. How often during the last year have you found that you were not able to stop drinking once you
had started? | <*Answer_92*>|5. How often during the last year have you failed to do what was normally expected from you because of drinking? | <*Answer_93*>|6. How often during the last year
have you needed a first drink in the morning to get yourself going after a heavy drinking session? | <*Answer_94*>|7. How often during the last year have you had a feeling of guilt or remorse
after drinking? | <*Answer_95*>|8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? | <*Answer_96*>|9. Have you or
someone else been injured as a result of your drinking? | <*Answer_97*>|10. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested that you
cut down? | <*Answer_98*>| ||Information contained in this note is based on a self report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be
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