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Run: AUDIT-C Alcohol Screening

Use this AUDIT-C Alcohol Screening template to record the three validated screening questions, calculate the score, and document the follow-up plan in one pl...

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Participant & Screening Context

Participant Full Name (required)

Employee / Patient ID

Enter only if required by your organization's intake process.

Screening Date (required)

Screening Context (required)

Select the setting or reason this screening is being conducted.

Administering Clinician / Screener Name (required)

Participant Consent (required)

The participant has been informed that their responses are confidential, used solely for health screening purposes, and handled in accordance with applicable privacy regulations (HIPAA / organizational policy). Responses will not be used for disciplinary action unless required by law.

Yes No N/A

AUDIT-C Questions

Q1 — How often do you have a drink containing alcohol? (required)

Select the response that best describes the participant's drinking frequency over the past 12 months. (AUDIT-C Item 1 — scored 0–4)

Q2 — How many standard drinks containing alcohol do you have on a typical day when you are drinking? (required)

A standard drink = 12 oz regular beer, 5 oz wine, or 1.5 oz distilled spirits. (AUDIT-C Item 2 — scored 0–4)

Q3 — How often do you have 6 or more drinks on one occasion? (required)

Heavy episodic (binge) drinking indicator. (AUDIT-C Item 3 — scored 0–4)

Scoring & Risk Zone

Total AUDIT-C Score (0–12) (required)

Enter the sum of Q1 + Q2 + Q3. Verify against individual question values above.

Biological Sex (for risk threshold interpretation) (required)

AUDIT-C risk thresholds differ by biological sex per SAMHSA and VA/DoD clinical guidelines. This field is used solely for scoring interpretation.

Risk Zone (required)

Select the risk zone based on total score and biological sex thresholds. If 'Not disclosed', apply the more conservative (female) thresholds.

Non-Drinker / Score = 0 Confirmation

If total score is 0, confirm whether the participant is a non-drinker or declined to answer.

Clinical Notes & Next Steps

Contextual / Clinical Notes

Optional. Do not record unrelated PII. Limit to clinically relevant observations.

Recommended Next Step (required)

Select the primary action to be taken following this screening.

Follow-Up Date

If a follow-up appointment or re-screening is planned, record the target date.

Referral Resource / Contact

Record the specific resource or contact provided to the participant.

Clinician Signature (required)

By signing, the clinician certifies that the AUDIT-C was administered as documented and that the recorded score and risk zone are accurate.

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