Alcohol Screening

Alcohol Screening Instrument for Self-Assessment

Directions

Number a sheet of paper from 1-12. Read each question, one at a time, and simply choose one of the responses that fits your circumstance. Each response is weighted from 0 – 4 as indicated in parentheses. Place the score that appears in the parenthesis at the end of the response you’ve chosen next to the number of the question on your sheet of paper.

1. How often do you have a drink containing alcohol?

[ ] never (0)
[ ] monthly or less (1)
[ ] two or four times/month (2)
[ ] two or three times/week (3)
[ ] four or more times/week (4)

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

[ ] 1 or 2 (0)
[ ] 3 or 4 (1)
[ ] 5 or 6 (2)
[ ] 7 – 9 (3)
[ ] 10 or more (4)

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

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

4. How often during the last year have you been unable to remember what happened the night before because of drinking?

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

5. How often during the last year have you found that you were not able to stop drinking once you started?

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

6. How often during the last year have you failed to do what is normally expected from you because of drinking (e.g., missed deadlines, poor classroom or work attendance, failed committee responsibilities, inconsistent work patterns?)

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

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

[ ] no (0)
[ ] yes, but not in last year (2)
[ ] yes, during last year (4)

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

[ ] no (0)
[ ] yes, but not in last year (2)
[ ] yes, during last year (4)

9. How often in the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

10. How often during the past year have you had feelings of guilt or remorse after drinking?

[ ] never (0)
[ ] less than monthly (1)
[ ] monthly (2)
[ ] weekly (3)
[ ] daily or almost daily (4)

11. Have people annoyed you by criticizing your drinking?

[ ] no (0)
[ ] yes, but not in last year (2)
[ ] yes, during last year (4)

12. Have you ever felt that you should cut down on your drinking?

[ ] no (0)
[ ] yes, but not in last year (2)
[ ] yes, during last year (4)

To score your test click here.