Title Banner

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:

In the last 12 months:

Do you use any street drugs? 

If yes: Which one(s)? 

How often?

Screen completed by (Print name/signature)

 

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

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

*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:

THEN ASSESS FOR:

If at-risk drinker: 

If alcohol dependent drinker:

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.

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.