Alcohol Use Disorder Outpatient Intake
Alcohol Use Disorder Outpatient Intake
Intake for outpatient alcohol use disorder treatment including AUDIT screening and history.
Patient Information
Full name *
Your answer
Date of birth
Phone
AUDIT Screening
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times/month
2-3 times/week
4+ times/week
How many drinks on a typical drinking day?
1-2
3-4
5-6
7-9
10+
+ 12 more questions
About this template
Intake for outpatient alcohol use disorder treatment including AUDIT screening and history.
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