APPENDIX D

Sample Alcohol Screening Tools

Yale-New Haven Hospital Screening Tool

UNIT NO.

NAME

ADDRESS

BIRTH DATE (If handwritten, record name, unit no., and birth date)

DATE

Alcohol and Other Drug Screening

Do you ever drink beer, wine or liquor? 

If yes:

• On average, how many days per week do you drink alcohol?
• On a typical day when you drink, how many drinks do you have?
• What is the maximum number of drinks you had on any given occasion during the last month?

In the last 12 months:

• Have you ever felt you should Cut down on you drinking? 
• Have people Annoyed you by criticizing your drinking? 
• Have you ever felt bad or Guilty about your drinking? 
• Have you ever had a drink first think in the morning to "steady your nerves" or get rid of a hang over? ("Eye opener")

Do you use any street drugs? 

If yes: Which one(s)? 

• marijuana
• PCP
• illy
• cocaine
• heroin
• uppers
• downers
• other (specify):

How often?

Screen completed by (Print name/signature)

Detection and Intervention of Problem Drinkers in the ED – 
Brief Negotiation Interview (BNI) Screening Tool

d

*See reverse side for screening tests and assessment and incorporate findings into BNI where appropriate.

*If patient tests positively or has Hx of alcohol problems, assess for safe discharge with appropriate referrals and instructions.

CAGE Screening Tool

CAGE (in the last 12 months)

1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to "steady your nerves" or get ride of a hangover "Eye Opener"?

CONSUMPTION

1. On average, how many days per week do you drink alcohol?
2. On a typical day when you drink, how many drinks do you have?
3. What is the maximum number of drinks you had on any given occasion during the last month?

SCREEN IS POSITIVE IF:

A positive response on 1 or more questions from CAGE and/or Consumption:

• Men > 14 drinks/week or > 4 drinks/occasion
• Women and both sexes > 7 drinks/week
• over 65 years of age > 3 drinks/occasion

THEN ASSESS FOR:

• Medical problems: Black outs, depression, hypertension, injury, abdominal pain, liver dysfunction, sleep disorders
• Laboratory
• Behavioral problems
• Alcohol Dependence

If at-risk drinker: 

• Advise patient of risk. 
• Set drinking goals. 
• Provide referral to primary care.

If alcohol dependent drinker:

• Assess acute risk of intoxication/withdrawal.
• Negotiate referral i.e. detoxification, AA and primary care.

Continue exploring Pros & Cons and Assessing Readiness to Change if appropriate.

Reference: The Physician’s Guide to Helping Patients with Alcohol Problems. National Institute on Alcohol Abuse and Alcoholism, NIH Publication No. 95-3769.

TWEAK Screening Tool

"TWEAK" Test

Do you drink alcoholic beverages? If you do, please take our ‘TWEAK" test.

• T - Tolerance: How many drinks can you "hold"? (Record number of drinks in space at right.) (For next questions, check box at right for ‘yes" answers.)
• W - Have close friends or relatives Worried or Complained about your drinking in the past year? 
• E - Eye-Openers. Do you sometimes take a drink in the morning when you first get up? 
• A - Amnesia (Blackouts): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? 
• K - (C) Do you sometimes feel the need to Cut Down on your drinking?

To score the test, a seven-point scale is used. The tolerance question scores two points If a woman reports she can "hold" more than five drinks without passing out, and a positive response to the worry question scores two points, Each of the last three questions scores one point for positive responses. A total score of three or more points indicates the woman is likely to be a heavy/problem drinker.

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