| 1. | Now I would like to ask you some questions about your use of alcoholic beverages, such as beer, wine, wine coolers, or hard liquor like vodka, gin, or whiskey. Have you had a drink of alcohol in the past year?
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| 2. | During the last 3 months, on average, how many days per week did you have an alcoholic beverage? (answers range from 0 to 7 only) | ___ |
| 3. |
During the last 3 months, on average, how many drinks did you consume on a day that you drank? |
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| 4. |
During the last 3 months, on days that you drank any alcohol, how many times did you drink four or more drinks in one day? |
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This screen will be considered positive if a patient exceeds seven drinks per week (determined by multiplying the response to question #2 by the response to question #3). The screen will also be considered positive if the patient has had more than two binge episodes in the prior 3 months (response to question #4 >2). A positive screen indicates the need to proceed with a more indepth assessment of patients’ drinking and possible alcohol-related problems.
Source: Barry, K.L.; Oslin, D.W.; and Blow, F.C. Alcohol Problems in Older Adults: Prevention and Management. New York: Springer Publishing, 2001.